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State of Cali fornia—Enviro ental-Protection Agency <br /> 'corm Approved OMB'1 96`' 39(Expires 9-30-99) See Instructions 011 back of' e 6. Department of Toxic Substances Control <br /> ,idose print or type. Formde"signed for use on elite(12-pitch) riter. - Sacramento,California <br /> UNIFORM'HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> * f` is not required by Federal law. <br /> t, <br /> WASTE MANIFEST D 8D ' g 1161 P 7` 1 of 1 <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> 1#29 S�®+ Adm-d STM B. State Generator's ID <br /> to <br /> (V 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> G 6 7 D. Transporter's Phone0 RM1 <br /> P P 19 19 14 15121510 <br /> e� 7. Transporter 2 Company Name • 8. US EPA ID Number E. State Transporter's ID.[Reserved.] <br /> �! F. Transporter's Phone <br /> "V <br /> 9. Designated Facility Name and Site Address 10. US EP.etAD Number G. State <br /> Facility's ID <br /> D S L S L 6 Q A <br /> Z ROXIC FAVIRMENTAL TECH <br /> H. facility's Phone <br /> JD O 2 1 RAY ROAAD D R 9 4 5 2 6 5 Y (650)324-1638 <br /> <D CA <br /> ¢ 12. Containers 13. Total 14. Unit <br /> Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> O No. Type Quantity Wt/Vol I. Waste NAer <br /> e Nt� 'State - <br /> F= C—�Jtq a T/�/tr" �✓�!r /C J! �® €PA/CDNher <br /> G zl� y,; ,r-7 rool l <br /> 56 5`1 N-RAL <br /> C14 N b .R MW 3 U1 II stare <br /> 00 <br /> co E <br /> EPA/gher <br /> NR D <br /> o T `'FUMBU LI DS L Q.S. 3 III state <br /> 000 t AI t ' EPA/C)her <br /> R 1=3 Do Q5 <br /> Mill 9 311247 LU d. State <br /> VEPA/Other <br /> ff Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> N Lim 11 r A a. b. <br /> c Eft <br /> LU <br /> d. <br /> Z <br /> Q '15.',Special Handling Instructions and Additional Information 24 • (5011333-M <br /> t•- <br /> Q <br /> Z <br /> LU <br /> t— <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 /> 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 /> n 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 (fort to minimize my,waste generation and select the best waste management method that is <br /> d available to me and that I can afford. <br /> a <br /> Prin a Name Signature j' � d�F r t onth: _Qay ea <br /> w T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> ,eLU A {- ^'j►�,' an <br /> w 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 T Printed/Typed Name Signature Month Day Year <br /> LU E <br /> N R <br /> Q <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> L.,_.. <br /> L <br /> f 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Printed/Typed Name1�w <br /> a Month Day Year <br /> 1 � �, as �, - A,... 3 10.-P-1 <br /> Referem flude: E NOMMI DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> 22A(1/99) (Generators who submit hazardous waste for transport out-of-state, <br /> DTSC 80 <br /> EPA 87022A produce completed copy of this copy and send to DTSC within 30 days.j <br />