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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 age b. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitc riter. Sacramento,California <br /> UNIFORM HAZARDOUS enerator's US EPA ID No. Manifest Document 2. Page 1 Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFESTof <br /> ., <br /> Generator's a MailingAddress A. State Manifest Document Number <br /> Agm <br /> 20279473 <br /> F. . B. State Generator's ID <br /> OD >� , <br /> 4. Generator's Phone <br /> tV 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> LO <br /> pRwmsf EnvirammletalSof vfteq D. Transporter's Phone $10-3sz <br /> O <br /> ao 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved] <br /> F. Transporter's Phone <br /> Q <br /> U s' to F ci"i Na q d Site Address 10. US EPA ID Number G. State Facility's ID <br /> ' Emt 29th it s H. Facility's Phone <br /> Qv ar e, <br /> Z5 12. Containers 13. Total 14. Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> V <br /> No. Type Quantity Wt/Vol 1, Waste Number <br /> Z a. State <br /> non 332 <br /> a . . :eey ( , <br /> EPA/Other NIA <br /> O N b' State <br /> 00 <br /> cooE <br /> 4 R EPA/Other <br /> A c State <br /> o T <br /> co O <br /> R EPA/Other <br /> LU d. <br /> State <br /> t— <br /> Z <br /> LU EPA/Other <br /> U <br /> w <br /> N J. Additional Descriptions ff-or Materials Listed Above K. Handling Codes For Wastes Listed Above <br /> W <br /> C. d. <br /> J <br /> a <br /> Z 15. S ecial Handlin Instructions and Additional Information <br /> TS�. .: I r ,. 1. <br /> Z W 910)37 -51747I ;a <br /> LU <br /> J 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 economica11 <br /> 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 /> available to me and that I can afford- <br /> 0 <br /> Printed/Typed Name Signature Month Day Year <br /> R17. Transporter 1 Acknowledgement of Receipt of Materials <br /> wA Printed/Typed Name Signature Month Day Year <br /> N <br /> 11- 0 18. trans orter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed ed Name <br /> R Si nature Month Day Year <br /> T yp 9 <br /> w E # <br /> V) ( ` <br /> V19 Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> 1 20. FacilityCtwner 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 /> v <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) Yellow; GENERATOR RETAINS <br /> EPA 8700-22 <br />