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State of California—Environmental Protection Agency • <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See In6tructions on back of oaae 6. Department of Toxic Substances Control <br /> Please print or type. Forfn designed for use on elite(I -pitch) 'ter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. enerator's US EPA ID No, Manifest Document No. 2. Paget Information in the shaded areas <br /> s nor required by Federal law. <br />_ WASTE MANIFEST r of , <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number ,; R <br /> B. State Generator's ID <br /> A. Generator's Pone ( 5 <br /> n <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> LO <br /> CP <br /> D. Transporter's Phone <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved'] <br /> .. 3 F. Transporter's Phone <br /> V 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> �`..` H. Facility's Phone - <br /> 0 <br /> 4.,«« Q 12 Containers 13. Total 14 Unit r <br /> V 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number <br /> _Z a State <br /> t� <br /> A P /Other <br /> E <br /> O N b. State <br /> 00E <br /> 4 EPA/Other <br /> C R <br /> A <br /> o <br /> stare <br /> T <br /> co O <br /> R EPA/Other <br /> ae <br /> w d. State <br /> t— <br /> Z <br /> LU <br /> U EPA/Other <br /> LU <br /> N J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> b. <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> < x4��-�k > `_:' 'r��i �V.�f."'? / 1.,1 pt „ati�i,_ �� f'����� i L•� <br /> F- �bk'3'r_..�A"3.�eA d=rk�dt�•^& 0. 'k e c'*�.. 0p .t.:5..... - <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurate)y 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 /> d 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 /> oc available to me and that I can afford. <br /> O <br /> Printed/Typed Name Signature Month Day Year <br /> Z <br /> w TR 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> C14 A PrintecVTyped NameSignature pr' { Jr% ,, Month Day Year <br /> wR <br /> S e ?¢ <br /> LL p 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> T Printed/Typed Name Signature Month Day Year <br /> LU E <br /> < 7` <br /> N R <br /> t V 19. Discrepancy Indication Space <br /> Z F <br /> t — A <br /> h' C <br /> 1 <br /> L <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by his manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> yK' <br /> 1 <br /> l <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) <br /> EPA 8700.-r-22 �eliovr Ct�Jtf.S?.TO': }al IIdS <br />