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State of California—Envlr,move lot Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-99) <br />Please print or type. Form designed for use on elite 112-pitchl Triter. <br />C <br />n <br />n <br />v <br />a <br />C <br />C <br />�a <br />as <br />nz <br />lax C <br />aLL <br />Z <br />x <br />3 <br />n <br />C) <br />m <br />'a <br />N <br />v <br />C) <br />00 <br />ae <br />z <br />W <br />V <br />W <br />N <br />Z <br />0 <br />a- <br />ef <br />K <br />a <br />Z <br />O <br />a <br />Z <br />S <br />H <br />a <br />U <br />0- <br />GrlO <br />V <br />Z <br />1110 <br />W <br />0 <br />W <br />W <br />a <br />V <br />0 <br />See Instructions on back o' Te 6. Department of Toxic Substances Control <br />DO NOT WRITE BELOW THIS LINE. <br />DISC 8022A (1/99) Blues GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />EPA 8700-22 To: P.O. Box 400, Sacramento, CA 95812-0400 <br />UNIFORM HAZARDOUS <br />1. Generator's US EPA to No. Manifest Document No. <br />2, Page 1 <br />Information in the shaded araesV <br />WASTE MANIFEST T= <br />'`� O 1 V <br />H 1 g <br />is not required by Federal law. <br />,p ! 111 {/ 81 3 43' b' <br />1 <br />of a' <br />3 C e .tor N { Mml J Address. <br />A. Slate Manifest Document Number <br />,;;; 1.F <br />22390203 <br />_..t ,h r1 <br />�Vilioq <br />B. Slate Generator's ID <br />pTfljt7.vf <br />d. Genemmr's Phonel4"'ri 4BIl-30tl5 s LAA-3a.1s, <br />5. Transporter I Company Name 6, US EPA to Number <br />C. State Tronsporfer's ID [Reserved.] <br />ks r.. -r'3 L, , i., :, . g r} U u - <br />D. Transporter's Phone <br />tsc�19$7-u2n <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID [Reserved.] <br />�rr1'Ltl >y s. nv-is . 1:33:5 ZL T f.. 'r, it E y 3 3 N 2111 3 3 <br />F. Transporter's Phone $QO 3 <br />( } 84-2591 <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />JV9 P.Nfc:iti2'.wiN. C:I x:;LF <br />H. Facility's Phone <br />: i i `) <br />- <br />(870)86:3-7173 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and D Num6erI <br />12. Containers <br />13. Total <br />14Unit <br />No. <br />Tye <br />_ <br />Quantity <br />Wt/Vol <br />I. Waste Nu/m6er <br />r UN—ill _ . , s <br />i z a i . •:F::-xaszsy- <br />State V L <br />p <br />7�Do7y <br />ePof 4* <br />E <br />0 0 3 <br />c e <br />-711A 0 3 -1 <br />r <br />State <br />E <br />Cot - <br />EFA40thef, v-. M <br />R <br />Ci <br />., <br />A-... <br />T <br />:u: -.. tae-r0.:e �:u <br />state <br />O <br />74 <br />EPA/Other <br />R <br />:-t <br />_ <br />tJ <br />:!f <br />d' ixry pY. <br />- <br />stae . <br />EPA/Other <br />J. Additional Dss<rigYLn} far Materials Listed Above ,7 YH 7i'1 <br />K. Handling Codes far Wastes Listed Above MR <br />" 11A: iWlo( 3xn,3 1 ar 118: 7,94&47' ! /4.><$S I •a Slc: <br />ra <br />Is. <br />C. <br />a. <br />15. Special Handling Instructions and Additional Information <br />Job X 14tH -44811 Site :7850 S. RA TirldgeP,0r4 6t.81:0cictci <br />Banta is K'SLA exempt per 40 CYR 261.4(b) (1; exclusion, uVa proper ?.-Z ubr:n ba:sdlinq bazasrtous <br />ele.ierld... y. ' F.u3 i='l>ae 'L98 12' <br />$"ser euY. ,,..ac: D/Ak nAcXX 1RC04'RAC 24&R. 600:535-4053 4 'i i?P10t.-IR kauvlt`'TTwl SOUTemial. s,s... <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consig ii are fully and accurate]y described above by proper shipping name and are classified, pocked, <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />If 1 am is large gaanliq generator, I certify that I have a progrom in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economical%yy <br />Practicable and that) have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threotto human heat <br />and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br />available to me and that l can afford. <br />Printed/Typed Name <br />SNre <br />Month Day Year <br />A -1 r7- <br />r <br />-J,- <br />z of vY <br />T <br />d f Recei p t of Materials <br />Transporter17.' 1 Acknowleemenf o <br />R <br />Printed/Typed <br />Name ^ <br />Signature <br />Ma 11 Year <br />11 <br />�( <br />vDay <br />i a y� <br />18. Transports 2 Acknowled emenf of R ei 1 of Materials <br />R <br />T <br />Prinfed/Typed Nome <br />Signature <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />20. Facility Owner or Operator Certification of recei t of hazardous materials <br />covered by this manifest except as noted in hem 19. <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />DISC 8022A (1/99) Blues GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />EPA 8700-22 To: P.O. Box 400, Sacramento, CA 95812-0400 <br />