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Stoles of California—Envirenrrrentol Nofeetien Agrncy ,r <br /> F=en d OMB No.2050-0039(Expires 9-30-96) See Instructions on back�ge 6. _ Department of Toxic Substances Control <br /> int <br /> Please pror type. Form designed for use on afire(17pir'. writer, Socromente.California <br /> 1. Generator's US EPA ID Na- Manifest Document No. 2. Pagel Information in the shaded areas <br /> UNIFORM HAZARDOUS "j— •l r•t f I � �t z 'i I r <br /> WASTE MANIFEST n not required by Federal torr, <br /> _ of <br /> 3. Gerterwot's,Nrsme and Mailing Address A_ Stale Manifest Document Number t' t Y r• ' <br /> -:A E-._t Y c"Sl E 1-'D. , F'r.l: ;' _-_��„ ' t ' nz r. 9 . x 8.8 2 . <br /> S. State Gatxrator's]p r s r r `:i . <br /> nit A. Generator's Phone _q d <br /> 47 r <br /> O n 5.7 h•.gpnrter 1 Cempany Nome 6, US EPA ID Number C• State Rm <br /> Trrsporter's ID- <br /> spo _'1 �. I_ i,.i: :.i y._ `} ., .._ J. �_ � �', �'t• .r <br /> C? <br /> D. Traasparter's Phone i <br /> 7. Transporter 2 Company Name S. US EPA ID Number E. Sfvte 7ransportefs ID t': <br /> V <br /> F. Transporter sPh <br /> one <br /> d <br /> r9, Designated Fac il ty No and Site Address 10_ US EPA ID Number G. State Facility's ID _ <br /> Cc <br /> j i LL - •,t- - - - _ H Focirdy's Phone, <br /> V 12, Containen 13. Total 14. Unit <br /> 11. US DOT Description Including Proper Shipping Neme,Hazord Closs,and ID Number) No T De Quantity Wt/Vol [•.•Wase Number'. <br /> Staf� I <br /> T �I a) EPA/Other <br /> o E7. <br /> CO N b. r State <br /> c E - <br /> Rt I EPA/Other' <br /> o A <br /> 0 T c. State <br /> O <br /> tr R I EPA/Other. <br /> w •- <br /> r- <br /> Z d. State <br /> U.? EPA/C>ther-. ..c. <br /> z J. Additional Descripirons fo_r Materials listed Above K. Handling Codes for Wastes Listed Above <br /> CL <br /> f s ni� s --- s - <br /> 4SATI <br /> d <br /> Z <br /> O 15, Special Handling Instructions and,Additional Information <br /> w - <br /> a 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of-his consignment are fully and accurately described above by proper shipping name and are classified, <br /> Q puked,marked,and labeled,and ore in all retpeets in proper condition for transport by highway according to applicable international and notional government regulations. <br /> V <br /> If I am o large quontity generalor, I certify tial I have a program in place to reduce the volume and toxicity of wase generated to the degree 1 have determined to be <br /> d economically procilmble and that I hove selected the procticoble method of treatment,storage,or disposol currently ovoiloble so me which minimizes the present and future <br /> V) threat to human health and the environment;OR, R 1 am a small quantity generator, I hove mode a good faith effort to minimize my waste generation and select the best <br /> x waste mono meet method that is available to me and that I can oflord. <br /> 0 Prinled/Typed Nome t Signature. Month Day Year <br /> LZi.I R 17.'Transporter 1 Acknowled emeni of Rece;D1 of Metericls <br /> (� 4 Prinfed/Typed Name Signaturer AAomh Do Year <br /> LLtJ 8 18. Transporter 2 Acknowledgement of Recei t of Meterioh " <br /> RPrinted/Typed <br /> sir_ TNome Signature � Month Day Year <br /> O c <br /> R _ <br /> bLU <br /> iJ 19. Discreponcy Indication Space j <br /> V F <br /> A <br /> Z C <br /> L <br /> 1 20.-Facility Ctwner or 2Urator Certification of receiat of hazardous materials covered by this manifest e=ce t as nosed in hem 19. <br /> 7 Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DISC 8022A (1/95) Yellow: GENERATOR RETAINS <br /> EPA 5700-22 <br />