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State of California—Environmental Protection Agency <br /> -Form Approved OMB No.2050-0039(Expires 9.30-99) See Instructions on back ofwmae 6. Department of Toxic Substances Control <br /> Ple6se print or-type. Form designed for use on elite f 12-pitch liter. Sacramento,California <br /> 1Generator's US EPA ID No. Manifest Document No.. 2. Page I Information in the shaded areas <br /> . <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> i WASTE MANIFEST C D 8 T 4 S 4 _ 1 of I <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> INMMATED 20717942 <br /> 7 NamB. State Generator's ID <br /> LO e4erator's one N 5W t3-7m $ <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> LO ;. <br /> 00 <br /> O I£ s 4 9 14131 2 6 D. Transporter's Phone 162)324-163 <br /> a�� 9aD 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> .�d 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 Cr I t 10 10 10 1 91 4 S <br /> ISIio ENVIROMTAL x H. Facility's Phone _1638 <br /> cK 0 L SAX BOAS iF A 5 2 b <br /> �N I L B <br /> J <br /> a Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> V No. Type Quantity Wt/Vol I. Waste Number <br /> +`Mb Z a.VAM ACMW 3Ix 1 .. 14 State <br /> 213 <br /> EPA/Other <br /> c14 E b. ,� xI State <br /> o N 214 <br /> CO E 'f EPA/Other <br /> T FLUMM LININ U.S. 3 I III State <br /> (IMMEoD O e ®A ' ✓✓' EPA/Other <br /> Prill 136124, ON 13 ALLA-1 <br /> LU d. State <br /> Z <br /> w <br /> EPA/Other <br /> J. Additional Descri tions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> ti <br /> f Lim Ila. S OM FM FM a. b. <br /> UJI <br /> m, <br /> C. d. <br /> J <br /> Z 15. Special Handling Instrucijoris and Additional Information 24 19. MU=Y MRW#,, I <br /> O <br /> Z <br /> w <br /> 2 <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 /> < 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 /> practicable and that I have selected the practicable method of treatment,storage;'"or IVosal 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 good faith, rt to minimize my waste generation and select the best waste management method that is <br /> available to me and that Ica (ford. <br /> 0 <br /> >_ Printed/Typed Name i Signature ��" Month Day Year <br /> Vey <br /> w R12. 1611l, <br /> T 17. Transporter 1 Acknovyled ement of Receipt of Materials <br /> LU p Printed/Typed Name r"' Signature /t' Month Day Year <br /> R <br /> w0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> Q R Printed/Typed ed Name Signature Month -.-Day Year <br /> T YP <br /> LU E <br /> V) R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> _ C <br /> L <br /> 20, FacilityOwner 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 /> Y <br /> f <br /> Men E MM64M DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) <br /> EPA 8700-22 Yellow: GENERATOR RETAINS <br />