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State of Callforeia-4leafth and Welfare Agency f <br /> Form Approved OMB No.2056-0039(Expires 9-30•"" Department of Health Services <br /> Toxic Substances Control Division <br /> " Pleean print or type. (Form designed for use an e't ,:h typewriter)- � Sacramento,California <br /> UNIFORM HAZARDOUS Generators US EPA ID No. "'- Manifest e. Page 1 Information in the shaded areas <br /> Document No. <br /> WASTE MANIFEST p of Is not required by Federal law. <br /> S. Generators Name and Meiling Address <br /> A. State it er <br /> Gift mSdcln. > v�G� okz�s Cif,t7 <br /> vV1 •�+� �. .�.Q r.. B-State Qeneratoes ID� <br /> 4. Generator's Phone ff„�r ) i+. '� L' _ <br /> r. klilq <br /> S. Transporter 1 Company Name a. US EPA ID Number -C:State Trsmporler'a. <br /> ND.Transporters f?hone' <br /> ap T. Transporter 2 Company Name B. US EPA ID Number E.State Transportefa!D,,,.; .p*:, t <br /> g F.,Transporters <br /> 9. Designated Facility Name air Site Address 10. US EPA ID Number G._State Facility's iD ' <br /> ,. .t 5 . •> ' <br /> J <br /> U a �/n H. Facility's Phone 3 y <br /> r r.: 4'Q ...3 fp # 3 <br /> Z -: <br /> C <br /> 12. Containers 13. Total 14. <br /> tt t 1. US DOT Description(Inciudi no Proper Shipping Name,Hazard Class,and 10 Number) Quantity Unit <br /> A <br /> -j No. Type Wt!Vol f :-•�L . �: <br /> V-4a.a ,�y k. <br /> v ��/ 14,, Joel ealee-rtr i�Id- 'Lr 400,0,Ja air r" f '. <br /> z /J .�f <br /> op N / x EPA/Other :. <br /> E b- 4W* state r <br /> TE / a <br /> EPAl0lher <br /> R c. �r States. :} <br /> EPAIOther ; <br /> d' state <br /> U ' 7A/t7ther, <br /> ° J. Additional E)aserip"a for Materials Listed Above s + K. Handling Codes for Wastes Listed Above <br /> Z 11.r ' z #=s <br /> CL ',� I' c �r1, /y. �`%s -c. a- 1' _� arY .fi' ,r^l,g. k a. (//�_�� F '.y,•�'r. _ q; ti' <br /> 4` ` '.T 0 ,e_ t3. /i h '°•- M �rn� ' d't p -. y"�•''i*' dei` +F y -'t7 ' '3" �`.`+- k'a:. t y -s-,,; <br /> W �`� 3`•c- ; 'i-s ;: ,rc r - .• .� -� z� ,fir.-. <br /> C4' y1 , F zFSIx <br /> + .r <br /> Z .B r � r0 !�.' !�' ''✓Q#� r7; _� w, �C'h�is' i."� v4a�ax3` h'k ? h T` �sS v�'.�. <br /> Q t5. Special Handling Instructions and Additional Information <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully an' uratea Dqq�ff66��abwa p shipping name <br /> and are classified,packed,marked,and labeled,and are In all respects In proper condition for tran hfjlf y pr if�dl_ appli International and <br /> national government regulations. f, <br /> N 1 am a large quantity generator.I certify that i have a program In place to reduce the volume and toxic este genera�'�ne I have determined <br /> to be economioaty practicable and that I have selected the practicable method of treatment,storage,or I currently'evalla a which minimizes the <br /> `i present and future threat to human health and the environment:OR.If I am a small quantity generator,I hav ood IqIW minimize my waste <br /> generation and select the beat waste management method Mat is available to me and that I can afford. <br /> �rt�n�ted/Ted Name Sig tura Month Day Year <br /> i LTA r J1�d.LCs t -d <br /> Transporter t Acknowledgement of Receipt of Materials <br /> di Typed Name Signature ,. Month Day Year, <br /> ..Bportbr 2.AckpaIlledgement of Receipt of Materials <br /> ,ped NameSignature Month Day Year <br /> .cy indication Space <br /> ner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in hem 19- <br /> Lame Signature Month Day Year <br /> �. 47 f- 11-24K <br /> Do Not Write Belo is Line Yellow:TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> are obsolete. <br />