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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 of a 6. Department of Toxic Substances Control <br /> Please prinPor type. Form designed for use on elite(12-pitch) ter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. enerator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST f• LI t � k/ <br /> �� :r a of <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Numbers..i <br /> °tsfC K � � hob <br /> An.: <br /> ,,_�,�,'� B. State Generator's ID <br /> 4. enera or s 0`hone (,. ) 1 -., _ <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> h <br /> NIa0 <br /> O _ D. Transporter's Phone <br /> 00 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporters ID[Reserved.] <br /> QF. Transporter's Phone <br /> V 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> . Q I�'Aiti.«.:" r sa,� �d � tter <br /> ' h' 1 <br /> a+"1:�% �'{Je 9` `; 1.1 .#.-{ it'. . A..+,r "t...,, �:f_-r.. t1�1?§,_}, ,. > fir., e't e�;. H. Facility's Phone <br /> Q <br /> ]I. US DOT Description(includingProper Shipping Name,Hazard Class,and ID Number 12. Containers 13. Total 14. Unit <br /> V P P Pp 8 ) No. Type Quantity Wt/Vol 1. Waste Number <br /> ZState <br /> .gars' <br /> F>– <br /> > G r °t, ;.> EPA/Other <br /> N <br /> o N b. r State <br /> 00 <br /> 00 E <br /> 'V R EPA/Other <br /> CN A _ <br /> o T C. State <br /> 000 O <br /> R EPA/Other <br /> aG <br /> H d' State <br /> Z <br /> W <br /> V EPA/Other <br /> LU <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> a. b. <br /> w <br /> J <br /> C. d, <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> H <br /> Z <br /> L .3�t 4'jx <br /> W <br /> 9, 4 hY <>, terra 4 � <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 /> J <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 /> Npracticable and that I Dave selected the practica6le method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <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 /> O available to me and that I can afford. <br /> V Qrinted/Typed,Name p Signa]ure <br /> 1 Month Day Year <br /> - <br /> �i. i t <br /> w T 17. Transporter 1 Acknowledgement of Receipt of Materials ~ <br /> C7 R , <br /> w A Printed/Typed Name Signature ' <br /> ,? Month Day Year <br /> LU 5 <br /> P <br /> LL- B 18. Trans orter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed ed Name 8 TMonth Day Year <br /> T YP Si nature <br /> N LU E <br /> Q R <br /> V 19. Discrepancy Indication Space <br /> A <br /> Z <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 /> 0 <br /> T Printed/Typed Name Signature <br /> Month Day Year <br /> v <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) <br /> EPA 8700-22 Yellow: GENERATOR RETAINS <br />