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,St to of California—Environmental PrDlechon Agency <br /> Farm Approved OMB N0E,2050-0039(Expires 9 30 99) 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)typewriter Sacramento California <br /> UNIFORM HAZARDOUS 1 Generalors US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST / ! q ) s not required by Federal law <br /> ' f of � <br /> 3 Generator s Name and Mailing Address L l'leT 5 TI f<i A Slate Manifest Document Number 22970557 <br /> '545 E:, rot to, � <br /> O � B State Generator s IB <br /> n f <br /> 4 Generator s Phone ! 1 //n � S_ � (� Lo <br /> CV 5 Transporter 1 Company Name / 1 ( wr✓ b US EPA ID Number C Slate Transporter is ID[Reserved 1 <br /> to <br /> Co AME QiGAN VALLEY WASTE 00— 0 8 i T 8 78 D Transporter s Phone b0`10- di-4b4 J <br /> t7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved] <br /> IJ <br /> Q F Transporter s Phone <br /> fDA�> bfd -t�4�dy+`9�E 4 iSif ¢\ddregs[{ <br /> 10 US EPA ID Number G Stalf.AtyLIID0 0 0 1 9 Q 4 1 8 <br /> �:i"0 s (-tAI)q ROAf] <br /> FIANK CA 93 3387 O A L C G 0 1 9 G 8 I G h Facile s' }-0663.8181 <br /> 0 <br /> VJ 12 Containers 13 Total lit Unit <br /> 11 US DOT Description lincluding Proper Shipping Name Hazard Class and ID Number) rNo,'LType Quantity Wt/Vol I Waste Number <br /> Z_ a NON-RCRA HAZARGO(JSINAsTE l.ItIUii State ,2_2'1 <br /> G ♦ , EPA/Other <br /> ": E <br /> O N b State <br /> m E <br /> R EPA/Other <br /> 'o T c Stale <br /> act O <br /> R EPA/Other <br /> Of <br /> u„t d Slate <br /> F— <br /> z <br /> w <br /> V EPA/Other <br /> ' J Additional Descri iians for Materials Listed Above K Handling Codes for Wastes listed Above <br /> �ILY WATER a Ill b <br /> a <br /> w <br /> � c d <br /> J <br /> O15 Special Handling Instructions and Additional Information <br /> Q t LOVES <br /> �Z EMERGENCY PI-40NE 200 667 $Plf, <br /> LLJ <br /> 16 GENERATOR 5 CERTIFICATION 1 hereby declare that the contents cf this consignment ore fully and accurately described above by proper shipping name and are classified packed <br /> Q morked and labeled,and are in all respecis in proper condition for transport by highway according to applicable tnternahonal and national government regulations <br /> V <br /> If I am a large quantity generator,I certify that I have o progyram m place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> practicable and that I have selected the practicable method <br /> Tom <br /> storage or disposal currently available to me which minimizes Ike present and future threat to human healih <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 /> Q:: available to me and that I can afford <br /> OPrinled/T ped Name Signature T Month Day, Year <br /> w A 17 Tions orler I Acknowledgement of Receipt of Materials <br /> LU A Printed/Typed Name _ Signature Manch Day Year <br /> LU P <br /> sL Q 19 Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> T Prinled/Typed Name Signature Month Day Year <br /> LL, <br /> E <br /> N R <br /> V 19 Discrepancy lndicahon Space <br /> Z F <br /> — A <br /> I <br /> L <br /> 1 20 Facile Owner or Operator Certification of receipt of hozordous materials covered h this manifest except as noted in Item 19 <br /> PnNed/Typed Name Signature Month Day Year <br /> ' DO NOT WRITE BELOW THIS LINE <br /> ' DISC 8022A {1/99) Yellow GENERATOR RETAlN5 <br /> EPA 8700-22 <br />