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State of California—Environmental Protection Agency <br /> Form-Approved OMB No.2050-0039(Expires 9-30-99) I 'See Instructions on back o e 6. Department of Toxic Substances Control <br /> Please print or type. `Form d0,iter.esigned for use on elite 112-pitch) Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> s not required by Federal law. <br /> WASTE MANIFESTIm of <br /> Generator's Na n Mailing Address A. State Manifest Document Number <br /> stwktaCA 962" B. State Generator's ID <br /> .. <br /> 24 <br /> A. Generator's Phone ( , fa <br /> t� <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID(Reserved.] <br /> h <br /> W <br /> O 9 C D. Transporter's Phone <br /> CP 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> QF. Transporter's Phone <br /> V s' e F cilit Na d Site Address 10. US EPA ID Number G. State Facility's ID <br /> ,gymH. Facility's Phone <br /> O • CA Som C a' <br /> �_ ".., . <br /> C%I <br /> J Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> V No. Type Quantity Wt/Vol I. Waste Number <br /> Z a. <br /> :�.. _ ...., +, OIswabid <br /> State <br /> non GERG .s') d. EPA/Other <br /> E ' ' <br /> o N b" <br /> State <br /> co E <br /> R EPA/Other <br /> A <br /> o T C. <br /> State <br /> 00 O <br /> R EPA/Other <br /> LU� State <br /> d' <br /> Z <br /> w <br /> V EPA/Other <br /> LU <br /> v7 <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> . 11X30 <br /> a. b. <br /> IZ-< cd 15. Special Handlin Instructions and Additional Information <br /> hwdws <br /> w 'fitai,sxr`if <br /> 4 <br /> _ E.WtKW AVO., , CA, 962W c > r <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,pocked, <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 /> J 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 /> U) 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 /> and the environment;OR,if I am a small quantity generator,1 have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> O <br /> available to me and that I can afford. <br /> } Printed/Typed Name Signature Month Day Year <br /> Z °.. 4< A <br /> w <br /> O -T 17. Transporter 1 Acknowled ement of Receipt of ateria)s <br /> R <br /> w N Printed/Typed Name Signature Month Day Year <br /> O0 18. 'Transporter 2 Acknowledgement of Receipt of Materials <br /> Printed/Typed ed Name <br /> T yP Signature Month Day Year <br /> w E <br /> N R <br /> Q <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> ] <br /> b' <br /> f 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 /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700=22 <br />