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Form Approved OMB No.2050-0039(Expires9-30.99) See Instructions on bac' " page G. Department of Toxic Subsionces Con <br /> Please print or type. Form designed for vse on @fire 02-p -pe-rifer. Sacramento,California <br /> UNIFORM HAZARDOUS 1 Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST - +t' t '_I 1 f ;l r 5 t of 1 is not required by Federal law. <br /> 3. Generator's Nome and Mailing Address AY SfoteManifest Document Num`98i.1764 <br /> �` <br /> t_'.sem i a, I tiP LT0N A•�,r� . �� fit=.t'`T�li 1� I_:F1 a�'. i t' <br /> _ J B.State Generator's ID ry s e v <br /> {'- "'Ds l 1 _fir <br /> u'I d, Generator's Phone '=�-4 -;rte - <br /> CV 5. Transporter 1 Company Name 5. US EPA ID Number C..State Trans rter s ID.LO <br /> Q j Transporters Phone, <br /> 7. Transporter 2 Company Nome B. US EPA ID Number - - <br /> M Transporters ID zap + F y 1., <br /> QF.,Transporters Phone: �, '•: <br /> U 9. Designated Fccility Name and Site Address 10. US EPA iD Number G State faciliy s ID loj, « <br /> T�� i ^s" <br /> ,r} Z <br /> ytr O I _ H F0,4y's Phone " <br /> �l !_moi _ I-,�I.-`---- '-i='f. ,�s-,(, t �.1 i-t -.-.� ,� r_�-, „ i `nz. <br /> _ �7" <br /> Q12. Contoiners 13otal Unit <br /> U J 1. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) d.No. Type wantiy Wt/4. Vol L-Waste YNumber <br /> ~ Z i•IJ_liQ�-1=I- -'f� ':�(� 1iNt'fil_1� iliiTr 1_T1!�.IT Star-,J <br /> G WF���.^ .' '-' 'J1 � I 7 EPA/Other <br /> _ O N b' State <br /> ago E <br /> 4 R EPA/Okher <br /> v A <br /> _ o T <br /> Stale <br /> m O <br /> R EPA/Other <br /> Ce <br /> Us d. <br /> State <br /> Z <br /> LU <br /> V EPA/Other <br /> 1. Additional Descriptions For Materials Listed Above - K. Handling Codes for Wastes Listed Above - <br /> PUPSE WATER- a 6 <br /> w <br /> a F <br /> C d <br /> Z 15. Special Handling Instructions and Additional Inlormot:on <br /> v!IJTN 1I 4G T rT c:4 <br /> ft <br /> Z —'_A.1.- ,�toL• r'tt_'f i ' (i;_sL t -�`:'�: . <br /> LU <br /> ._ , - <br /> -J-+ <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare thot the contents of this consignment ore fully and accurotely described ubove by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in oil respects in proper condition for transport by highway according to applicable internationol and notional government regulations. <br /> If I am a large quantify generator, I certify that I hove a program in place to reduce the volume and toxkiy of waste generated to the degree)hove determined to be economicol)y <br /> procticob'.e and that I hove selected The pract'ecobie method of treatment, storage,or disposal currently available to me which minimizes the present and Future threat to human heaith <br /> and the environment:OR, if 1 am a small quantity generator, I have made a good faith eHorf to minimize my waste generation and select the best waste management method that is <br /> available to me and Thai I can afford.-- <br /> O <br /> } Printed/Typed Nome Signature Month Day Year <br /> w z 2 r <br /> LU T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> � R <br /> Li M Printed/Typed Nome Signature / / /',) Month Day Year <br /> LLJ <br /> 0 1 B. Transporter 2 Acknowledgement of Receipt of Materials <br /> RPrinted/T ed Name <br /> T YP Signature Monrh Day Year <br /> ul E <br /> < R <br /> Q <br /> L) 19. Discrepancy Indication Space <br /> — Z F <br /> — A <br /> C <br /> I <br /> L <br /> '•' 1 20. Facility Owner at Opitrator Ceriificasion of receict of,6azocdous materials covered by this monist except as noted in Item 19, <br /> T Printed/Typed No f ' Signature / /l Manth Day Year <br /> Y !�' / r •, <br /> `t ^ r J J- / - � ` f <br /> — DO NOT WRIT/r'16LIC41415 LINE. i <br /> DTSC 8022A (4/971 <br /> EPA 6700-22 <br />