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State of California—Environmental Protection Agency <br /> ,Form Approved OMB No.2050-0039(Expires 9-30-99) S@@ Instructions OA bQC�C O 9@ 6. Department of Toxic Substances Control <br /> >4P11f9se print or type. Form designed for use on elite(12-pitc rifer. Sacramento,California <br /> 63. <br /> NIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page I Information in the shaded areas <br /> 24is not required by federal law. <br /> 20062042 <br /> ° WASTE MANIFEST 17141614121 9 i F of I <br /> erator's Name and Mailing Address A. State Manifest Document Number <br /> S. AdWIT5 STM <br /> B. State Generator's ID <br /> LO er r e1172 <br /> co <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> op h <br /> OIC 0 9 141512161 ?,D. Transporter's Phone <br /> O <br /> aD 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> h V F. Transporter's Phone <br /> Q <br /> ®yU 9. Designated Facility Name and Site Address 10. US EPA MO Number G. State Facility's ID <br /> A ID 10 10 191415121 6 <br /> 1 51 71 <br /> : � RGAI{i ENVIRIAWTAL TE4'R H. Facility's Phone <br /> O 2W1 SAY RIM I} 1 19 S 4 S 2 5 5 7 (650)324-1638 <br /> - GA 94M 12. Containers 13. Total 14. Unit <br /> �Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number( <br /> U No. Type Quantity Wt/Vol I. Waste Number <br /> State <br /> ® Z-,,.j .5 nrrl-I�Z 4CZ Pr � �✓/a,��� /� f_ EPA/Other <br /> Diu <br /> O N b . . a II State <br /> 213 <br /> 00 E // EPA/Other <br /> -4 R `/ <br /> DM <br /> 14M 9 Z= RIM <br /> o T `.FLMDU( I LILMTAS.�3 61 III ^� state <br /> O R e .�MCA 120 (�,� -� {� /✓EPA/Other <br /> MUM <br /> c d. i P State <br /> w , <br /> F" <br /> tZZ EPA/Other <br /> Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> b <br /> T I Ii . 4,coftr a I <br /> C. d. <br /> 1Z 15. Special Handling Instructions and Additional Information <br /> 0 24 HR. EUGM KMVM #: { ) <br /> F <br /> Q <br /> Z <br /> LU <br /> t- <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 /> Umarked,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 /> a 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 <br /> 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 /> Oavailable to me and that I can afford. i <br /> r Frintod/T�ZFName `• Signature � d a. f b�ontf ay ear <br /> - y J1 JC �.. <br /> Z ' .G'' t`/ `i rxir <br /> w T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> s <br /> R <br /> �+ f/� S, , AQont�7 Dam eay <br /> R testi <br /> W <br /> u- 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 T Printed/Typed Name Signature Month Day Year <br /> LU E <br /> cn R <br /> Q <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> 1 <br /> L <br /> 20. Facili Owner or O erator Certification of race; t of hazardous materials covered b this manifest exce t as noted in Item 19. <br /> T-' inted/Typed Name Signature Month Day Year <br /> Reference ars E IMON218 DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br /> r ; <br />