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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 O e 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(I 2-p;tch riter. Sacramento,California <br /> Ri 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST C A I D I @171 # 61 1 1 .31 + of 1 <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> I <br /> M V914 <br /> ad <br /> \\i B. State Generator's ID <br /> erfera"tor's one <br /> 1 Ill ° <br /> Ni 5. Transporter 1 Company Name 6. US EPA ID Number C. Stat!ajro s orter;s,ID-[Re erved.] <br /> in0 77 <br /> O RINICWIRIMMAL W. Ci .A D It 18191412 D. Transporters Phone (M324-16M <br /> O <br /> n <br /> CP 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID(Reserved.] <br /> F. Transporter's Phone <br /> Q <br /> V 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> u JA I DI 0101 S # <br /> TC EIVIRMOTAL TECD H. Facility's Phone <br /> H p L U 224-1 <br /> %.-0 PALO <br /> -' 12. Containers 13. Total 14. Unit <br /> Q <br /> 11. US DOT Description(including Proper Shipping Nome,Hazard Class,and ID Number) <br /> q"�V No. Type Quantity Wt/Vol I. Waste Number <br /> N�M Z a. VAM MMM3 0129111111 State <br /> 213t- <br /> 1S GEPA/Other <br /> E g '122 a <br /> NO N b. V ITE 231 1I State <br /> oo <br /> co E 214 <br /> EPA/Other <br /> �' t y I� �t �+ aay9 'p�Fg^ i..; <br /> DW <br /> 6 A c. Lt LO.S. J 111 State <br /> co T <br /> co O t S LM CMAMIXETON) <br /> EPA/Other 512 <br /> ' R 0 C� 1 :` a J r <br /> +� d. State <br /> i <br /> •� <br /> EPA/Other <br /> J. Additiofnal Descri tions for Materials Listed Above K. Handling Codes For Wastes Listed Above. Codat MS FM M5 <br /> LiN <br /> 6. <br /> C. d. <br /> Z <br /> 15. Special Handling Instructions and Additional Information ti 24 HR. EAUGM RERMs IMM-3M <br /> Q iti; <br /> Z �yf <br /> LU <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 /> 1 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 good faith effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford. <br /> 0 <br /> >- Prl'ated/Typed Name Signature .•'n' Month Day Year <br /> f' <br /> w T <br /> (.D R 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> w p Printed/Typed Name Signature Month Day Year <br /> LL- 0 18. Transporter 2 Acknowled ement of Receipt of Materials <br /> T Printed/Typed Name Signature Month Day Year <br /> w E <br /> N R <br /> (Qj 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> L <br /> 1 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 /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />