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State of California—Environmental Protection Akency <br /> Form Approved OMB No.2050-0039(Expir 9-30-99) See Instructions on back of b. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite 112-pitch)ty�er. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> L3. <br /> IFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST I °f <br /> tor's Name and Mailing Address : A. State Manifest Document Number <br /> 2-4311476 <br /> 1IXR4kW 1W <br /> . <t B. State Generator's ID <br /> LO OaYterotor's Phone j?60 <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> h <br /> O <br /> amp mlay4s' #0wr�� D. Transporter's Phone <br /> O <br /> C? 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved] <br /> J F. Transporter's Phone <br /> J <br /> U 4. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> Z 118tt V .- H. Facility's Phone <br /> .r 12. Containers 13. Total 14. Unit <br /> U11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol 1. Waste Number <br /> State <br /> 7- 214 41 (gfettlto1a.t3* e3a:*%illxtor tsoiuenek) EPA/Other <br /> cV E b. State <br /> O N r a it r..r, i sa a»p, <br /> 000 E nw—a I`""Dous VLM LTQIJI,l EPA/Other <br /> v R <br /> o T ii �Zr s state <br /> 00 0 )WARDOW Uh3TE SOLID EPA/Other <br /> R Dm P F 15 ` <br /> State <br /> Z III + + LII` EPA/Other <br /> w <br /> 1. Additional Descriptions for��jj�,aterial Listed Above K. Handling Codes For Wastes Listed Above <br /> r 30L%rENTi BANE CON�'Fi[ E .I►Ev: °. 6. <br /> a Wit_#128 L.a PRfrF°I f,F # 107 <br /> rP C. d. <br /> Z <br /> O 15 Special Handling Instructions and Additional Information <br /> HIMarmits for, and will acceppt <br /> z LACY Ct �tl3': (400) 746-7449* <br /> w SEE E.R.O. the waste this generator is <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this constynment are fully and occurate)y ae'seribed 6bbleb;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 /> Jr If I am a large quantity generator,I certify that I have,o program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> a practicable and that I have selected the rracticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> rn 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 /> a available to me and that I can afford. <br /> OPrinted/Typed Name Signature Month Day Year <br /> U <br /> Z t <br /> w T 1 . Transporter 1lAe ment of Receipt of Materials <br /> R Month Day Year <br /> LW p Prin ,Typed Name Signature <br /> R <br /> LU S <br /> P <br /> 0 0 18. Trans otter 2 Acknowledgement of Receipt of Materials <br /> TPrinted/Typed Name _—]Signature Month Day Year <br /> LU E <br /> V) R <br /> U 19. Discrepancy Indication Space i <br /> Z F 1l°Ud1 <br /> A <br /> I <br /> nrT <br /> L <br /> 1 20. FacilityOwner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19. <br /> Printed/Typed Name Signature Monll Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> V <br /> ellow: TSDFSENDS THIVCOPY TO GENERATOR WITHIN 30 DAYS. <br /> (Gen,rators whKK submit hazardous waste for transport out-of-state, <br /> DTSC 8022A (1/99) produce completed copy of this copy and send to DTSC within 30 days.) <br /> EPA 8700-22 <br />