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v <br />C <br />U <br />Z <br />17 <br />O <br />w <br />H <br />U <br />U <br />II <br />�mre at onrornm—cnvrronmental rmtechon Agency <br />Form Approved OMB No. 2050-0039 (Expires 930-991 See Instructions on back of page 6. Department of Toxic Substances Control <br />Please print or type. Form designed for use on elite (12 -pitch) s writer. <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />EPA 8700-22 To: P.O, Box d00, Sacramento. CA 95812 0400 <br />UNIFORM HAZARDOUS <br />aerator's US EPA ID No. Manifest Document I <br />2. Page I <br />Information in the shaded or.., <br />WASTE MANIFEST <br />is not required by Federal law. <br />of <br />3. Generator', Noma and Mailing Address <br />A. State Manifest Document Number <br />-" - <br />B. State Generator's 10 <br />4 <br />5, Transporter I Company Name 6, US EPA ID Number <br />C. State TransporMi s ID [Reserved.) <br />0 <br />D. Transporfer's Phan. <br />10 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. Stat. Transporter', ID [Reserved.) - <br />( <br />F. Transporter', Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />C <br />d <br />H. Facility's Phone <br />/ <br />11. US DOT Description - (including Proper Shipping Name, Hazard Class, and ID Number <br />p I nz g p pping I <br />12. Containers <br />13. Total <br />I4. Unit <br />No. <br />Type <br />Quantity <br />Wt/Vol <br />I. Waste Number <br />- <br />is - <br />- <br />Shute <br />G <br />- <br />EPA/Other <br />E <br />> N <br />b' - <br />state <br />i E <br />t R <br />EPA/Other <br />A <br />T <br />state <br />i O <br />R <br />EPA/Other <br />d <br />Stale <br />i <br />l <br />t <br />EPA/Other <br />1. Additional Descriptions kr Materials Listed Above <br />K- Handling Codes for Wastes Listed Above <br />b. <br />c <br />d. <br />15. Special Handling Instructions and Additional In(ormati.n <br />16. GENERATOR'S CERTIFICATION: (hereby declare that the contents of this consignment are fully and accvrotely described above by proper shipping name and are classified, packed, <br />marked, .ad labeled, and ore in all respects in proper condition for transport by highway according to applicable international and notional government regulations. <br />If I am large quantity gene tor, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economical <br />practicable and that) me selected the practicable method of treatment, storage, o disposal currently available to me which minimizes the and future threat to human health <br />Present <br />and the environment; OR, if I a a small gvanety generator, I have made a good faith effect to mmtmize my waste generation and select the best waste management method that is <br />v.d.do to me and that I caa afford. <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />T <br />17 T ns .iter I Acknowled ement of Receipt of Materials ' <br />A <br />R <br />Pr d/Typed Nome <br />i <br />Si luie <br />9^ - <br />t <br />Month Day Year <br />5 <br />l_Z t <br />wi <br />a <br />IBS Transporter 2 Acknowled ement of Recei l of Materials <br />T <br />Printed/Typed Name <br />Signature <br />Month any Year <br />E <br />R <br />19. Discrepancy Indication Space <br />IF <br />A <br />C <br />I <br />L <br />20. Facility Owner. or O erator Certification of receipt of hazardous materials <br />covered by this manifest except as noted in Item 19.. <br />T <br />Priated/Typed Nome <br />Signature <br />Month Day Year <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />EPA 8700-22 To: P.O, Box d00, Sacramento. CA 95812 0400 <br />