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State of California—Environmental Protection Agency <br /> F6ft. Approved OMS No.2050-0039(Expires 9-30.99) See Instructions on back of a 6. Department of Toxic Substances Control. <br /> Please print or type. Form designed for use on elite(12-pitch)Oiter. Sacramento,California <br /> 1 Generator's US EPA ID No. Manifest Document,No , 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST C A D 7 4 6 4 9 5. s of is not required by Federal law. <br /> 0 3. Generator's Nome and Mailing Address A. State Manifest Document Number <br /> Im <br /> SG® B: State Generotar s tD <br /> .0 Ip � <br /> i A. Generator's Phone( d: JM F11"M <br /> i <br /> NO5. Transporter 1 Company Name 6. US EPA ID Number C. StateTronsporter's Piz Reserved 1. <br /> 00 <br /> .6 RONIC EIVIERMAL TECH. C A D 6 9 9 4 5 2 6 D. Transporter s Phoria <br /> O <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Tronsporter's ID[Reserved.] <br /> ®/J <br /> +� F. Transporter's Phone <br /> `V 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> -Q C A 9 4 5 <br /> KIC ENVIROMTAL TECH H. Facility s Phone <br /> 09: 2061 BAY C A D 6 6 9 4 5 2 6 5 (63)324-1638 <br /> U_ EAST PALO ALTO CA 94383 <br /> Q12. Containers 13. Total 14. Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> V No. I Type Quantity Wt/Vol I. Waste Number <br /> Z a. WME FAIIIT IMATED AATERIAL 3 U11263 11 State <br /> 3 G Prfl# E 201 127 <br /> EPA/Other <br /> O N 6. State. <br /> 65 ,..E ERA/Other <br /> N A PrflE32 7 127 ® @ � tJ ffi t? 4 � � 1 <br /> c. `state <br /> 0 L� <br /> R Prfl# E 341372 @ @ 5' "� ® e 7 S L� EPAIOthar <br /> w d. State <br /> Z ( IDE: <br /> 1# E 1247 126 @ D 6 -Dm 0 b 2 6 1 EPAfOtber <br /> J.Additi ID ti s r i IN lWiBove K. Handling Codes for Wastes Listed Above <br /> 1r A a b 0 <br /> LU <br /> Ce <br /> c d. <br /> J M t.l <br /> Z <br /> O 15. Special Handling Instructions and Additional Information 24 0. MMUMNA.1 Im <br /> LU <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by propershipping 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 quantify 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 is nomica11 <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 and the environment;OR,if I am a small quantity generator,I have made a-gocd faith effort to minimize my waste generation and select the best waste management method that is <br /> ac available to me and that I can afford. <br /> OPrinted/Tye a / Signature ,.' i Month Day Year <br /> Z G"�4J* , tele" <br /> 6 T17. Transporter 1 Acknowledgement of Receipt of Materials <br /> C4 R <br /> A Printed/Typed Name Signature Month Day Year <br /> W <br /> "s ..ao✓azi.r &-4 7AI. "t�m:...vr ua OZ4,x reg. <br /> U_ 018. Trans orier 2 Acknowledgement of Receipt of Materials <br /> T Printed/Typed Name Signature Month Day Year <br /> LU E <br /> 0 N R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> L <br /> I 20. FacilityOwner or O eras Certification of receipt of hazardous materials covered by this maKiTe-3Vxgept as noted in Item 19. <br /> Printed/Ty �° Pj Signature �' Month Day Year <br /> pe a <br /> blernm Ruder: E IM41351 DO NOT WRITE BELOW THIS LINE. <br /> Yellow: 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 />