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State of California Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on (sack o 6. Department of Toxic Substances Control <br /> Please®yiat or type. Form designed for use on elite f 12-pitch) er. to Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM <br /> HAZARDOUS � , of is not required by Federal law. <br /> WASTE MANIFEST " � 1 f.,, 7 °° r. - <br /> 3. Generator's Name and Mailing Address f E r`R (. P tr� A. State Manifest Document Number <br /> J ,V ,l 0 °f w v tea' <br /> c S B. State Generator's ID <br /> LO 4. Generator's Phone si �•, '"'d 'V '� `,d" .F 7" '^je <br /> N T p t .} om n� p @•> e T v 6. US EPA ID Number C. State Transporter's ID[Reserved.) <br /> toy `' <br /> 4 ..d. p <br /> �° �c r � Q,� u, ),1 te.°S � � a� � «� D. Transporter's Phone 5 7S5""` <br /> c) <br /> CP 7. s fg,( �C�fF{" p T�y s-` t cC ¢8. US EPA IIDNumber E. State Transporter's ID[Reserved] <br /> G el 1 5 F 9 _9§ a y� � A..• ., �,,. <br /> F. Transporter's Phone <br /> Q <br /> V j a e an Address 10. US EPA ID Number G. State Facility's ID <br /> � YUMMY Y i�V : � �f k a x 0 S 3, <br /> .6 H. Facility's <br /> -0 <br /> W <br /> J= <br /> 12. Containers 13. Total 14. Unit <br /> V 1 1. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number <br /> Z a!s�[f�'6`P..f €.. fry `- ,"~'C, ,g�`.k�,1''dt Gs ' 7" State <br /> 3 Ci t��`�& sl ,� C r 5! � e , .. P a EPA&t �a cL <br /> d' ..+� .l �t' <br /> O N b. State <br /> 00 <br /> 000E <br /> 4 R EPA/Other <br /> A C. State <br /> o T <br /> op <br /> R EPA/Other <br /> State <br /> Z <br /> w <br /> V EPA/Other <br /> LU <br /> J Additio al De; ri w 3'or Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> n <br /> 0 11a <br /> V) 11b <br /> U-1 11C <br /> ne C. d. <br /> LldQ <br /> 0 15. Special Handling Instructions and Additional Information �� <br /> Z ..mt:.. <br /> _ <br /> WEM .. .'�IG x.1'4 C31MUNGI- r a`�° lid- <br /> I_ iebb <br /> „t <br /> N <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I am a large quantiy generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> o practicable and that ITselected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> N and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> W available to me and that I can afford. <br /> Printed/Typed Name Sign re% Month Day Year <br /> Z <br /> 6 T 17. Trans orter ;Acknowled ement of Receipt of Materials <br /> w p Printed/Typer4la e J',r� n p' Signatur f f�/f��� M�.c�. fhe fDay�; reams`` <br /> R 1/ !' y r a � e a^ <br /> WS �;. '\k`. ',p`Ff` I �R,fad""' •..,... ,J,.• rP;dr? �P. '" (.,•`` .x r <br /> U_ 0 18. Trd'ns orfer 2 Acknowled eme it of Receipt of Materials c ` <br /> R Printed/Typed Name Signature Month Day Year <br /> w E <br /> LI) R <br /> T <br /> Q <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I <br /> L <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> v <br /> DO NOT WRITE BELOW THIS LINE. <br /> 22A (1/99) Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC 80 <br /> EPA 87022A To: P.O. Box 400, Sacramento, CA 95812-0400 <br />