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$ to of California—Environmental Protection Agency See Instructions on back AF b. Department of Toxic Substances Control <br /> rm Approved OMB No.2050-0039(Expires 9-30-99) Sacramento,California <br /> Please print or type. Form designed for use on elite(12- <br /> IV ` 1. Generator's US EPA ID No.,,; Manifest Document No. E2Poge 1 Information in the shaded areas <br /> "° UNIFORM HAZARDOUS is not required by Federal law. <br /> atT� <br /> F WASTE MANIFEST A A 8 7 4 9 <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> 01 20876353 <br /> B. State Generator's ID <br /> L k <br /> h <br /> A. GBAeratof s one ( t <br /> JIM mmR <br /> D <br /> C. State Transporter's 1 . eserved. <br /> N 5. Transporter 9=Company NameLn <br /> b. US EPA ID Number P [ i <br /> DTransporter's Phone <br /> O AL S121 fil )324'1 <br /> O <br /> ftz <br /> � 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> F. Transporter's Phone <br /> n V 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> QIC 10 1 D I B Le 191 41 51 21 <br /> 10— Z RLINIC RVI TTL to -� <br /> H. Facility's Phone <br /> �.. 1638 <br /> 0c . :PAY AA CA B 0 9 � � 6 S ifi l <br /> }Q12. Containers 13. Total 14. Unit <br /> V 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number <br /> ..State <br /> Z <br /> � EPA/Other <br /> 3 c <br /> N b. <br /> State <br /> E A LT 1.0. . 3 III <br /> o <br /> m E a AI A7 EPA/Other <br /> v R y� <br /> v A State <br /> o T ` / <br /> Oro EPA/Other " <br /> R S <br /> w d. II 213 <br /> State <br /> Z EPA/Other <br /> E 32M EVAM-0 12-'La G <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> fir a b. 0 <br /> w1a t <br /> Ce d <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information a <br /> 0 <br /> Q <br /> Z <br /> W <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 /> -CC <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 /> 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 racticable method of treatment,storage,..ar disposal currently available to me which minimizes the present and future threat to human health <br /> V) 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 /> oc available to me and that I can afford. <br /> s $i nature \ Month Day Year <br /> PrinterlType Name y (y r/ <br /> , <br /> 17-1 OiL <br /> d <br /> W T 1 . Trans orter 1 Acknowledgement of Receipt of Materials <br /> R Si nature 1' Month Day Year <br /> LU A Printed/Typed Name g i p <br /> W1710 <br /> I/ s!'Z•Jd f�,a- <br /> U- 8 18. Transporter 2 Acknowledgement of Receipt of Materials Month Day Year <br /> 0 T Printed/Typed Name Signatures <br /> LAJ E <br /> R <br /> U19. Discrepancy Indication Space <br /> ZA <br /> C <br /> I <br /> L <br /> 20. Facili Owner oreratorCertificatio n of receipt of hazardous materials covered b t 's ma 'fest exce t as noted in Item 19. Month Day Year <br /> g <br /> Sinatur <br /> Printed/Ty qt� T J p � r <br /> Referem lmdven E ON40M DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> (Generators who 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 />