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State of California—Environmental Protection Agency <br /> yF rma i P t or type.OMB Form 050-003 39(Expires 9130(12-pitch rifer.0-99) AOL See Instructions on back O e 6. DepartmentSacof Toxic SubstancCalifornes Control <br /> ento, <br /> ' UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST I D 1 7 4 6 4 2 9 �� is not required by Federal law. <br /> of <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> 20876353 <br /> B. State Generator's ID <br /> {.� e�ierd ors one <br /> WN 5, Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> 00 <br /> o . D. Transporter's Phone IS <br /> OP 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> F. Transporter's Phone <br /> " l> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> rya ; 3 5 2 5 <br /> Ce 1c EPIRMUMAL II H. Facility's Phone <br /> `%—Ce I PAS' t 4 5 6 � +M324-1638 <br /> racm Pain wnrl, CA %MJ <br /> Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> No. Type Quantity Wt/Vol I. Waste Number <br /> Z a <br /> State <br /> 3 G EPA/Other ` <br /> ON b' �ol3nIII State <br /> oo E # 1 ? -, <br /> R <br /> cte✓ <br /> t t <br /> r EPA/ <br /> Oher <br /> -4 R <br /> vA ool W11.) <br /> 00 State <br /> A her <br /> 14, <br /> mi— <br /> wd. i State <br /> Z 22 <br /> EPA/Other <br /> n. <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> &r' a b. <br /> W tad. la <br /> ve <br /> C. d. <br /> J <br /> Q <br /> Q15. Special Handling Instructions and Additional Information 24 Mi. % #a it 1 <br /> Q <br /> Z <br /> W <br /> 2 <br /> F <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 /> J <br /> J 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 /> 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 /> 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 /> 04 available to me and that I can afford. <br /> O <br /> Printe44,TypedName r _,. Signature ? Month Day Year <br /> V <br /> R 17" vans orter T Acknowledgement of Receipt of Materials <br /> LU 8 D' 4� :� � Ld Printed/Typed Name Signature a 1�'y Month Day Year <br /> w P .r <br /> 1 t.: f'�n/. ' :�.i."v +""tee 0 <br /> It 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> Printed/Typed Name Signature Month Day Year <br /> W E <br /> V) R <br /> Q <br /> („J 19. Discrepancy Indication Space <br /> Z F <br /> A `. <br /> C <br /> 1 <br /> L <br /> j 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> I E DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A EPA 8700-22(1/99) .. Yellow: GENERATOR RETAINS <br /> - <br />