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late of Californio—Environmental Protection Agency <br /> spm dpproved OMB No 2050-0039(Expires 9 30 991 See Instructions on back o page 6 pepartmeni of Toxic Sublstances Con rc <br /> Please print or type Form designed for use on elite f 12 pitch)typewriter Socrcinento Ca ifornla <br /> 1 Generator s US EPA ID No Manifest Document No 2 Page I Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required ay Feaeral taw <br /> WASTE MANIFEST <br /> F3 Generator s Name and Mailing Address - A Stare Manifest Document Number / rwry ��F <br /> 7 1 <br /> 8 State Generator s ID <br /> - � r <br /> 4 Generator s Phone (�[}C; ) C's 02 1 <br /> h <br /> N 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporters ID[Reserved I <br /> pr-r^ s n T+ r t + sRru r i 7 D Transporter s Phone p <br /> s:V`i r�.s.r,s� li A,a_-s-� VVA31 E' 0I,_ , � � tS 7 ti x.00-72 -_f0,45 <br /> 4. aD 7 Transporter 2 Company Name 8 US EPA ID Number E State Tronsporter s ID[Reserved] <br /> r <br /> F Transporter s Phone <br /> IF <br /> {9�y yDes�q^sn-aled{Facility Name`and Site 011- <br /> xAddress 10 US EPA 10 Number G Stale Facility <br /> y-s'yID { <br /> Q 1i 40 Ll�s�IA1- vE-Vj ICE LFII- co, INN J iJ 0_19 9 Y 5 n Irl <br /> Z 700 S SATO S�'T H Facility s Phone <br /> 1 <br /> Q12 Containers 13 Total 14 Unit <br /> Q 11 US D07 Description(including proper Shipping Name Hazard Class and ID Numberl No Type Ouant-y Wt/Vol I Waste Number <br /> el a Slate <br /> *40r',1-RGPA }''r'11!AROCJS :-r.' ATF k_I NIQ - 22'1 <br /> CIL'- .1,Q T w ii !1 f 4 Ei /Orbit <br /> G C R L St✓� <br /> N E 6 Sla e <br /> N Y <br /> E EDA/Other <br /> R <br /> v A c Stale <br /> O T <br /> O EPA/Other <br /> R <br /> kLU d State <br /> r <br /> I EPA/Other <br /> I <br /> 1 Additional Descriptions for Materials listed Above K Handling Codes for Wcstes Listed Above <br /> Z <br /> 0 OILY WATER a �; b <br /> C d <br /> Q <br /> Z 15 Special Handling Instructions and Additional tnlormotion <br /> GLOVES <br /> EME=RGENCY PHONE 209"£57-3,357 <br /> r <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurotely described o6ove by proper shipping name and are clossiried pec'�sed <br /> morked and labeled and are is all respects in proper condition for transport y highway according to opp icoble international and national government regulatians <br /> J <br /> -+ If I am a large quantity generator t certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I hove determined to 6e economicsy <br /> practicable and that I have selected the practicable method*I 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 I have mode 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 /> Signature Si i Month Day Year <br /> Printed/Ty ed Naj i g Ij ///� <br /> Alf r,?om/ 61iti` <br /> T 17 Trans arter 1 Ac6owled ement of Receipt of Materials - <br /> R Si nature ' A J Manik— Day Year <br /> A Printed/Typed Name [� F g ! ! I <br /> w P <br /> p 18 Trans orter 2 ACknowled ement of Recei t of Malerials `1 <br /> TPrinted/Typed Name Signature Month Day Year i <br /> E <br /> R <br /> U19 Discrepancy Indication Space <br /> A <br /> C <br /> 1 <br /> 20 Fouh Owner or O erntor Certification of receipt of hazardous materials covered by this manifest exceot es noted in Ilerwl9 <br /> T Printed/Typed Name i L _-� Signrlrure -Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE <br /> !> Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> 22A{1/94] (Generolors who submit hazardous waste for transport out of sto e <br /> DISC 80produce completed copy of this copy and send to DISC within 30 cloys <br /> EPA 87022A J j <br />