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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 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-p/tch) r. Sacramento,California <br /> 1. enerator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS f ! ,F is not required by Federal law. <br /> WASTE MANIFEST 01 " <br /> s <br /> 3. Generator's Name and Mailing Address/ 'c /1 sem" &d% ° A. State Manifest Document Number ` <br /> 9 <br /> B. State Generator's ID <br /> LO <br /> LO 4. Generator's Phone,d°.=-4!'y-1 �`c `•.gyp ` Ff ,{g"� F}y,;:'-�C"G #1° ..,'�. ea rl.i <br /> N 5. Transporter 1 Company Namer G � }�k,t N 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> O G J ' 3 � (� D. Transporter's Phone �1. <br /> O +.s <br /> ao 7. Tra s art r C n,N 8. US EPA ID Number E. State Transporter's ID Reserved. <br /> R A J 4 -v 9-7,14,71919 13 <br /> 7 F. Transporter's Phone <br /> Q <br /> "V 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> gs mm Tris <br /> 1Z 2CI RMAJ � D0FAME ME H. Facility's Phone <br /> ct� 12. Containers 13. Total 14, Unit <br /> Q 11. US DOT Description including Pro.ePr Shipping Name,Hazard Class,and ID Number Type Quantify Wt/Vol I. Was <br /> V N - , No. te Number <br /> State �' t <br /> O N b. State <br /> coE <br /> EPA/Other <br /> 4 R <br /> 11 A C. State <br /> o T <br /> 00'0 O <br /> R EPA/Other <br /> LU d. <br /> State <br /> Z <br /> LU EPA/Other <br /> V <br /> w <br /> V) J. Additional Descriptions foaterials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> V) S <br /> Cd C. d. <br /> Z 15. S ecial Handlin Instructions and Additional Information re <br /> p P gtt _l .. <br /> Z IMAUR t. R€,�i4 NCY t 0s TA <br /> ��: �E� I � E 9U. P S <br /> LU qpq <br /> t- <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 quantity 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 economicall <br /> Npracticable and that I have selected the practicable method of treatment,stora0e,or disposal currently available to me which minimizes the present and future threat to human hecolth <br /> and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minir/iize my waste generation and select the best waste management method that is <br /> Oavailable to me and that I can afford. v <br /> r Printed/Typed Name f Signatures," i {f .Month Day Yea t, <br /> Z �._sc;e, V <br /> C�u t T 17. Transporter 1,,,cknowled ement of Receipt of Materials <br /> g rans � . <br /> LU p Printed/Typed. ,,, Signatu " / ° P. <br /> Month F rDay� ,dYear; <br /> S <br /> si B 18. Traa4 orfer 2 AcknowIed ementt of Receipt of Materials <br /> O R Printed/Typed ed Name Si nature Month Day Year <br /> T yp g <br /> w E <br /> N R <br /> Q <br /> VF 19. Discrepancy Indication Space <br /> Z A <br /> _ C <br /> I <br /> L <br /> 1 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 />