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State 4 California—Environmental Protection Agency <br /> +>Form Approved OMB Na.,2050-0039[Expires 9 30 991 See Instructions on back of page G Department of Toxic Substances Control <br />'y Please print or type Form designed for use on chic(12 pitch)typewriter Sacramento California <br /> I Generators US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS � .G is not required by Federal law <br /> WASTE MANIFEST Gf71 � Is� / t 71 a1 <br /> 1 191 <br /> F3Genercitor l s Name and Mailing Address it 7(> �X� t A State Manifest Docur ant Number <br /> ` i u 1 <br /> Cc) _ B Stale Cenerolor s ID <br /> Ln <br /> 4 Generators Phone � <br /> n <br /> CV 5 Transporter I Company Natne i 6_ US EPA ID Num[ef' C Stole Transporter's ID[Reserved <br /> LO <br /> a3 � ir7. J <br /> rNer,�Y w�4+ruV �r��rs,.p..f s�i WI TIC-00.1L �' v 4 D Transporter's Phone -' <br /> 7 Transporter 2 Company Name w 8 US EPA W Number E State T09sporter s ID[Reserved I <br /> F Transporter's Phone t <br /> U 9 Desy�nated Faulty Name and Site Address 1 US EPA ID Number, G State Facility s ID <br /> Z e04 <br /> H Facility s Phone <br /> 12 Containers 13 Total 14 Unit <br /> U1 1 US DOT Description{including Proper Shipping Name Hazard Class and ID Number) No Type Quantity Wt/Vol I Waste Number <br /> Z a State <br /> z NCSN41Cf?A HA74lRn011)'� WA4+TIF- w 1Q1 110 21?$ <br /> (-01LY-WATEP T 7- EPA/Other <br /> cv E b Stara <br /> O N <br /> °p <br /> ao EPA/Other <br />' � A c State <br /> o T <br /> R <br /> amp O EPA/Other <br /> R <br />' t- d stats <br /> 11, EPA/other <br /> U <br /> J Add itionol Descriptions Far Materials Listed Above K Handling Codes for Wastes Listed Above <br /> a <br /> OILY WATER <br /> V) <br /> U-1 <br /> c d <br /> T <br /> Q <br /> � 15 Special Handlm Instruchans and Additional Information <br /> P 9 <br />■ Uj <br /> t- <br /> 16 GENERATOR S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above b proper shipping name and are classified packed <br /> Q marked and lobeled and are in all respects in proper condition for transport by highway according Io applicable international and national government regulations <br /> If I am a large quanta generator I certify that I have a program tit place to reduce the volume and toxic of waste generated to the degree I have determined to be economically <br /> rZ practicable and that I have selected the practicable method of treatment,storage or disposal current] oval#able 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 made a good faith effort to mi ze my waste generation and select the best waste management method that is <br /> available to me and that I can afford <br /> U Prim 1 �Nord,,? "" Signatur¢e, �/ � I � Mont�Day Year <br /> Z �• <br /> tt.t T 17 Transporter t Acknowledgement of Receipt of Materials <br /> APnr}t I/Tfyped Name yy Signature Mont Do,,, Year <br /> LU 5 *? <br /> P <br /> ii 018 Transporter 2 Acknowledgement of Recei pt of Materials <br /> Q R Printed/Typed Name Signature Month Day Year <br /> T <br /> LU E <br />' Q R <br /> U F 19 Discrepancy indication Space <br /> Z A <br /> C <br /> 20 Fac[[L Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> T Pnni Typed Nome Signatvr Mon,l�� Day <br /> 7� wear f <br /> 15) <br /> d PCr NOT WRITE BELOW T INE <br />' DTSC 8022A 11/991 Yellow GENERATOR RETAINS <br /> EPA 8700-22 <br />