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State of Cal lFornlo—Envirarrmental Protect+or Agency <br /> Form Approved OMB No 2050-0039(Expires 9 30 99) See Instructions on back of page b Deportment of Toxic Su6stonces Control <br /> Please pant or type Form designed for use on elste(f2 pitch)typewriter Sacramento California <br /> `UNIFORM HAZARDOUS, s 1 Generator's US EPA ID No Manifest Document No 2 Pago I Information in the shaded areas <br /> ' _ M is not required by Federal law <br /> WASTE MANIFEST �_? k ,y f 1 '1 1 a' N, ' J of <br /> 3 Generator a Nome and Mailing Address A 'State Manifest Document Number 1 2.1.65809 <br /> r� <br /> B State Generators ID <br /> t <br /> 4 Generators Phone 1 }a� rw£ s trfl kid a lio_ ,U 5 Transporter 1 Company Name 6 US EPA ID Number C State Tronsporter's ID(Reserved 1, 1 <br /> ?1 fir{ � 31�efts VPL F"/ �i4 A'11 f,(-- Oi w xl a t: �a it � 7 7 - e <br /> O D Transporter s Phone ¢° att` i <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID 1Reserved 1 <br /> 1 , <br /> e, Q f Transporter s Phone, <br /> , <br />"' V ;ort esienat Fgdfry e(af Sa eAtidresi', TO US EPA ID Number G Stdkj Fgc1llitt ll Q '"o 2 fj 1.1 -1 b <br /> R�^�7 r',a�g^} A Sg5r 7 ., Y .r ;r� �� ,p H Facile PhQn 1 .t 81 <br /> Q EAl�i 9...t13�' ' �S if4�` i' # ,� '�i y 'l 51 ' ! f > kQw�C7 +`w!''¢11 u.Y117 ' <br /> 12 Containers 13 Total 14 Unit <br /> 11 US DOT Description(including Proper Shipping Name,Hazard Class and 3D Numberl <br /> tNo Type Quantity Wt/Vol I Waste Number <br /> i 01"0 F�CHA H44ANDOUZZ3, VV A"-il >E LIC,'a,zlo State K21 <br /> N EPA/Other <br /> ~r d <br /> N b <br /> State <br /> co E <br /> R EPA/Other <br /> A <br /> T ` <br /> sra re <br /> O <br /> R EPA/Other <br /> d <br /> State <br /> V EPA/Other <br /> LU <br /> J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> OILY 1f1 ATZsT:il a b <br /> W i , <br /> oc c d <br /> J I L <br /> 3 1 <br /> 15 Special Handling Instructions and Additional informationf <br /> Q � � a C �.1 1 y„A.,�t `tel jf� {_� 11�tf.���s Y..� �. 7— <br /> z 'r <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fuPy 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 inlernal�anal and national government regulations <br /> i � <br /> If i am a large quantity generator„I certify that I have a program in place to reduce�1hs volume and toxicity of waiJe generated to the degree I have determined to be economically <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 /> and the environment OR if 1 am a small quantity generator I have mode a good faith effort to minimize my waste generation and select the best waste management method that is <br /> avapla6le to me and that I can afford <br /> 0 <br /> �nnfed/Typed Ncme r y Signalure } Month Day Year <br /> CD T �17 Transporter 1 Acknowledgement of Receipt of Materials <br /> A Prmted/Tpad�dme Signature + Month Day Year <br /> C ,t'�`*+� <br /> B 113 Trefts oder 2 Acknowledgement of Recei t of Materials ° <br /> TPnnfed/Typed Name Signature Month Day Year <br /> w E <br /> R <br /> F 19 Discrepancy Indication Space <br /> A <br /> C <br />' f 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Year <br />' DO NOT WRITE BELOW THIS LINE <br />'DISC 11022A (1/99) <br /> EPA 6700-22 (c 1 nw CAI NCRla`VK RETAIN` <br />