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Sbtr s rli'ornia—Environmenlel Protection Agency <br />Fcrm a(ppi eyed OMB No.2050-0039(Expires 9-30-99) See Instructions on back Of Page 6. Department of Toxic Substances Control <br />Pte. -.,mss pri:"or':ype. Form designed for use on elite/11-pifch)lypr Sacramento, California <br />], <br />UNIFORM HAZARDOUS <br />1. (: alar', US EP ID No. Manifest Dowmenl No. <br />� <br />2. Page I <br />Information in the shaded oreos <br />WASTE MANIFEST <br />{ ''ZC; <br />; al <br />i s not required by Federal low <br />I: <br />3 Genterator`,e s Nome and Moihn@ Address - J ('} s,j<W U}(1 \„jr i -�'\( <br />4 as <br />A. State Manifest Document Number 9 0 3 4 0 <br />V� CS <br />B. Stale Generator's ID <br />_ c <br />�- <br />4 y��( <br />d <br />5 Transporter I Company Name 6. US EPA ID Number <br />C. Stale Transporter's ID ]Reserved.] <br />l <br />D. Tronzporte/s Phonq � —7 <br />� � F-7 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />7. <br />E. Slate Transporter's ID [Reserved.] <br />F. Transporter', Phone <br />S- Designated-EQaity Name and Site Address .v t 10. US EPA ID Number <br />G. State Facility's ID <br />!i <br />H. Facility, Phone <br />71. US DOT Description )including Proper Shipping Name, Hazard Class, and ID Numb <br />12. <br />12. Containers <br />13. Total <br />Quantity <br />14. Uniter) <br />Wt/Vol <br />I. Waste Number <br />Type <br />State C <br />G <br />- <br />/ <br />1 <br />lt..�/ <br />EPA/Other-, --\. <br />F <br />�I N <br />b. C✓'% f 1 t�..��('v't�(�.�,..�','�:-_i � s � \...iC""v�. � <br />� <br />state. <br />C <br />> <br />EPA/ er' <br />P <br />A <br />' <br />�_ <br />ri <br />.� <br />�` / <br />�f <br />�`1, <br />T <br />s! .- .. ... <br />f- l ] 1 <br />slate f. <br />1 <br />]("til <br />c L <br />EPA <br />K <br />i <br />I --'y <br />1 <br />Stale { r <br />r. <br />r <br />j <br />J Add 1 anal De pt ons for MalarlaIs sled Abover^ <br />K Handling Codes for Wastes <br />Listed Above <br />i <br />i I <br />C. <br />d. <br />15 Special H.,dlimp 1 action cfAdd t oval Inh.,rietlbn <br />16. GENERATOR'S CERTIFICATION: I hereby declore that the contents of this consig men) ore fully and occurately describedabove by proper shipying name and are classified,pocked, <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to opplica6le international and national government regulations. <br />If lam a largequanYly generator, I certify that) have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br />predicable and that I hove selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health <br />and the environment; OR, if I am a small quantity generator, I have made a good kith effort to minimize my waste generation and select the best waste management method that is <br />available to me and that I can afford. <br />P6nted/Yype8-Na m.A <br />signalara - <br />Maa(h _ _,-paY ' vsa <br />17 T nsporle I A4royldr,m,al of Receipt of Materials / <br />mdr Typcdh :'Sign <br />luie/- <br />Month-- Day year <br />16- Transporter 2 Ackno-ledpe ent of Recel t of Materials <br />hinted/Typed Name <br />Signature <br />Month Day Year <br />I S. Discrepancy Indimlian Space MAY 7 4 20CE <br />OD <br />„ <br />§(� <br />L <br />20. Facility Owner or Opercder Certification of recai t of hazardous materials covered by this manifest except as noted in Item 19. <br />j Printed/Typed Name <br />signature <br />Month Day Y. or <br />DO NOT WRITE BELOW THIS LINE. <br />DTs€ 8922A (1/99) Yellow: GENERATOR RETAINS <br />FFA `700-22 <br />