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t State of California—Environmental Protection Agency1 $ O s et <br />;{ Form Approved OMB No. 2050-0039 (Expires 9-30.96) ee Instructions on bac'- " page 6. Depar�{mentof Toxic Substances Corrrc <br />Please print or type. Form designed for use on elite (171 pewr. ler. r. Socromento California <br />rt <br />UNIFORM HAZARDOUS <br />1. Generator's US EPA ID o. Manifest Document No. <br />2. Page 1 <br />=information in the shaded areas <br />WASTE MANIFEST <br />CAD 9t Y'34 %.34 iii) <br />$ . L4 <br />1 <br />is not required by Federal law. <br />of <br />3, Generator's Name and Mailing Address MQT'L R- (;',JAR 0 Capt? <br />A. State Manifest Document NumberSso <br />to <br />Q �j <br />B. State Generator's ID <br />C14"AN <br />FCA C �+ 9533 <br />LO4. <br />Generator's Phone �� y'?) G 3 Cj_. c"d• 2 C <br />µ , 5 . <br />O <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporters ID M € <br />0? <br />J <br />F —44 L VN! iC 131; F-, . R <+'r `,"$ ' <br />D. Trcrosporter's Phone <br />Q <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. Slate Tromportees ID <br />U <br />Q <br />f. Transporter'. Phone <br />Z <br />9. Designated Facility Tame and Site Address`-' ' -+ '+ 10. US EPA ID Number <br />G. State Facil' 's 10 <br />O <br />!00C 0C SOUTH I STR S'T <br />H. Faciliy'sPhone <br />iL: E-'fL t Y, `ice5 4 Ci--"' S�'Z:"45945 <br />U <br />209+"`.3d�� <br />Z <br />11. US DOT Description (including Proper Shi m Name, Hazard Class, and ID Number) <br />P ( 9Shipping <br />12. Containers <br />13. Total <br />14. Unit <br />No. <br />Type <br />Quantity <br />Wt/Vol <br />1. Waste Number ` <br />= <br />~ <br />� <br />a. <br />HA ZA,f QUE3 R.3;ftS t i 1 fA'V D �,. V _ <br />}ynt <br />� <br />state 342 <br />G <br />•�I <br />LZ=. 0,b, .r is• 7 f Li�SL i i <br />{e NAs.*Z Sr:e. <br />EPA/ Other <br />�r <br />-a 7, r �. r <br />CO <br />OD <br />N <br />b. <br />Stare <br />4 <br />E <br />V <br />R <br />EPA/Other <br />d <br />A <br />00 <br />T <br />C. <br />State <br />1 <br />O <br />c, <br />R <br />EPA/Other ` <br />w <br />Z <br />d• <br />State <br />W <br />U <br />EPA/Other <br />U.1 <br />h <br />Z <br />0I <br />JAdditional Descriptions for Materials Listed Above <br />i A . DO34i <br />K. Handling Codes for Wastes Listed Above <br />V) <br />b. <br />a 14 01 <br />Q <br />C. <br />d. <br />Z <br />O <br />15. Special Handling Instructions and Additional Information t w' `T t . ;..= 5 t' :• y . i ^ :.� Z; K ;i v' <br />t- <br />..•i =. �. it: y i _ *tICC- lit•;i—' 74-nO 24HR <br />Z <br />LU <br />_ <br />.A_ 008 7 <br />77i r, *10 c11: ,r, I .t.T 'AP2 TER. AS T ^=r' ARY <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, <br />Q <br />packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />U <br />If I am a large quantity generator, 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 <br />deconomically <br />practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future <br />rn <br />threat to human health 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 <br />waste management method that is available to me and that I can afford. <br />O <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />U <br />Z <br />A <br />17. Trans orter 1 Acknowled ement of Recei t of Materials <br />NPrinted/Typed <br />Name <br />Signature <br />Month Day Year <br />UjP <br />w <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />LL <br />T <br />Printed/Typed d Name <br />tT /SignatureMonth <br />Signa <br />-T <br />Day Year <br />O <br />L <br />A <br />N19. <br />Discrepancy Indication Space <br />Q <br />U <br />F <br />A <br />Z <br />C <br />I <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />...I -_ 10, 1 <br />71 <br />�... <br />7 DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/95) <br />EPA 8700-22 <br />White: TSDF RETAINS <br />