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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 page 6. Department of Toxic Substances Control <br /> Please print or type Form designed for use on ehte(12 pitch)typewriter Sacramento California <br /> 1 Generuior's US EPA ID No Manifest Document No 2 Page i information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal dew <br /> WASTE ANI <br /> - al <br /> 3 Generator s Name and Ma.hng Address A State Manifest Document Numbe21139109` 9 <br /> +tca�.f <br /> O r / } B State Generator s ID <br />' ^ 4 Generators Phone(f ft ; <br /> N 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved] <br /> LO <br /> m �y a C T ry D Trans oiler's Phonep�(�oi 'i+ss+s r� <br /> O o P#.0-I 6I *'7 t4 YJ*'4Y..3.."'10 ,,0VAaJTt r,. �sdr a t � ' '�h ! 1, P SOU k V4"'�''s 45 <br /> O° 7 Transporter 2 Company Nome B US EPA ID Number E State Transporter s ID[Reserved] <br /> F Transporter s Phorte <br /> U G State FaciliVs ID <br /> 9 Designated Facih Name and Site i0 US EPA iD Number <br /> 1 1 <br /> � � ��:}•� M Foulii�s Phone <br /> r <br />�O r C G 1 F <br /> �. 12 Containers 13 Total 14 Untt <br /> U11 US DOT Des�c�enphan(including Proper Shipping Name Hazard Class and ID Number) No Type Quantity Wt/Vol I Waste Number <br /> z a NON 6 <br /> 4 1 <br /> -RP,1 4A7A'.=iD0LJ*%WA.S!3F J 1,1,00 State 221 <br /> 2 <br /> ~ OILY 4dVATEXt9 T i Y' EPA/011ier <br /> 3 c - <br /> E b Stale <br /> CN N <br /> coE <br /> � EPA/Other <br /> V <br /> -4 A c State <br /> C3 T <br /> 880 O EPA/Other <br /> R <br /> tLU d stare <br /> M- <br /> w EPA/Other <br /> V <br /> 1 AAdditional Descriptions for Materials bsted Above K Handling Codes for Wastes Listed Above <br /> d OILY ATEK o b <br /> ate c d <br /> J <br /> Q15 Special Handling Instructions and Additional information f <br /> w x M ��GENCY 1��4+�'ME 209- 6r4357a�� � f��'i��►� to �r� �nU r l�vt�� � ��t��� <br /> tr <br /> Atmmd { <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this const nment are fully and accurately described above by proper sh ppmg name and are classified packed <br /> Q marked and labeled and are in all respects in proper condition(or transport by highway according to applicable international and notional government regulations <br /> J <br /> -� If I am a large quantty generator I certify that I hove a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economtca1 <br /> a. practicable and that I have selected the rachcpblo method of treatment storage or disposal currently available to ma which minimizes the present and future threat ro human health <br /> srs <br /> and the environment OR if I am a sip I 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 /> Qfrigted/Tytped Name _ ( Signiisturo' r' Month Day �rYear <br /> T 17 Transporter T Acknowledgement of Receipt of Materials <br /> w N Printed/Typed'!i vne „er" Signature �'"� Month Day Year <br /> wP fr f '�--- r!f v / +r Pi lr •,"'' <br /> ts. R 18 rans orter 2 Acinowled ement of Recei t of Materials <br /> TPrinted/Typed Nome Signature Month Day Year <br /> LL, <br /> E <br />' � R <br /> 19 Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I 20 Facility Owner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item > <br /> T Prm ed Nome Signatures Month Day Year <br /> DOI E BELOW T <br /> r , <br /> 11TSC 1022A 11/991 Yellow GENERATOR RETAINS <br /> EPA 8700-22 <br />