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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) ,. ;„ See Instrucfiions on back of age 6. Department of Toxic Substances Control <br /> Pease print or type. Form designed for use on elite(12-pitch) riter. Sacramento,California <br /> M UNIFORM HAZARDOUS eneratot s US EPA ID No. Manifest Document 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST s, is not required by Federal law. <br /> 1614121 <br /> } of <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> re <br /> x <br /> I� SUMISIM, sow B. State Generator's ID <br /> -3= Coated Erm <br /> N 5. Transporter 1 Company ar �: PA ID Number C. State Transporter's ID[Reserved.] <br /> h <br /> O 4 D. Transporter',Phone <br /> O C I AL 1� 4 2 7 (&%)324-� <br /> O <br /> OP 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID(Reserved.] y <br /> F. Transporter's Phone <br /> X�) V 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> D Q 1 16 1 6 5 <br /> XD z <br /> IC EVIROMMAL1W, t� H. Facility's Phone <br /> 0 a DAA' 6 S M"a + l324_lGig <br /> J ), 12. Containers 13. Total 14. Unit <br /> Q 11. USDOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> No. Type Quantity Wt/Vol I. Waste Number <br /> Za. state <br /> ~ EPA/Other <br /> 3 E h414 6 32M MR IN ( a t <br /> o N '-VAM MM ATE I II State Nei <br /> 214 <br /> OD E EPA/Other <br /> 01 13 10 <br /> A PPM E 34M W1 <br /> o T L€!.S. 3 Y III state <br /> coo 0 S lI !ACEW) EPA/Other 512 <br /> R Mil BMW Mi 229 Im <br /> 16'1 151 <br /> LU d. State <br /> Z <br /> LU <br /> EPA/Other <br /> V <br /> w <br /> 1. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed,,Above <br /> Line Iia. Eft Collin.- DL15 FM FM <br /> LU <br /> C. d. <br /> a <br /> 0 15. Special Handling Instructions and Additional Information 2412. MOSM RERM MOM-3M <br /> i <br /> Q <br /> Z <br /> w <br /> S <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,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <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 economically <br /> CL practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> N <br /> and the environment; at I if I am a small quantity generator,I have mgde p good faith effort to mirymizq my waste generation and select the best waste management method that is <br /> Ce available to me and that 1 can afford. !� <br /> >- Prince ed Name Signature Month Day Year,,-, <br /> , <br /> ZIt ! f �! �.' <br /> LU T Transporter Acknawled ement o Recei t of Materials <br /> w= R <br /> A Printed/Typed Name fj� f }"' signature r ',Month Day Year! <br /> WS f ®t•- ✓ 'd^',,� ,..Y.," ie_:'f;7 ` r f j',( >�.l- `�,,,:s,°,,,,r ..d_ t/;.' tJ� <br /> LL_ b 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> LU E <br /> N R <br /> (Qj 19. Discrepancy Indication Space <br /> A <br /> — C <br /> L <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials cover b tis manifest except as noted in Iteffl 19. <br /> T Printe Typed Name Signat Month Day Year <br /> )u-44A4 f <br /> ! � <br /> blerem t S OMM DO NOT WRITE BE W THIS LINE. <br /> Ilow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A(1/99) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy,and send to DTSC within 30 days.) <br />