Laserfiche WebLink
Sttcte,f Califbrnia—Environmental Protection Agency <br /> Form Approvrd OMB No.2050-0039(Expires 9.30-99) w4OF ar See Instructions on back of Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch) Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST <br /> of <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number ro22579-1 4 <br /> , <br /> B. State Generator's ID <br /> LOA. Generator's Phone <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> to <br /> CP D. Transporter's Phone <br /> O <br /> o0 7. Transporter 2 Company Name B. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> _.J F. Transporter's Phone <br /> F(aj 10. US EPA ID Number G. State Facility's ID m <br /> 9. Designated Facility Name and Site Address � r <br /> .Z <br /> Facility's Phone <br /> .y H. <br /> ,c <br /> w <br /> Q12. Containers 13. Total 14. Unit <br /> V 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol' S Waste Number <br /> State <br /> Z a <br /> 2 ri <br /> p i , EPA/Other <br /> ;la R <br /> G t., <br /> a 4�:.l.]_ t <br /> �_J ;f. <br /> E State <br /> o N b' i V, <br /> 00 <br /> EPA/Other <br /> v R <br /> N ,s i State <br /> v A C. M 4 `uul <br /> o T <br /> 00 O EPA/Other <br /> R <br /> Ce UJ d. State <br /> Z EPA/Other <br /> w <br /> V <br /> wK. Handling Codes for Wastes Listed Above <br /> J. Additional Descriptions for Materiofs Listed Above <br /> Z a. . # 6. <br /> �" <br /> CL <br /> LU <br /> d. <br /> J <br /> Z <br /> 15 Special Handling Instructions and Additional Information <br /> Q <br /> Z <br /> Uj ,. ..,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 /> < marked,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 economically <br /> a practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> and the environment;OR,if I am o 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 /> d' available to me and that I can afford. <br /> O z f E Month Day Year <br /> Sigriature.. / �P <br /> Printed/Typed Name re" ! <br /> Z <br /> w T 17. Trans orter 1 Acknowledgement of Receipt of Materials <br /> t'J _ Month Day Year <br /> B F rioted/TypedName r- ` Signature ._ p- r T may* <br /> Uj <br /> LU S <br /> O <br /> P <br /> 18. Transporter Month Day Year <br /> 2 Acknowledgement of Receipt of Materials w <br /> R Printed/Typed Name Signature" <br /> T <br /> NE <br /> R <br /> V19. Discrepancy Indication Space <br /> Z IF <br /> A <br /> L <br /> 20. Facility Owner.or Operator Certification of receipt of.hozardous materials covered 6 Ais manifest except as noted;in Item 19. <br /> _ Signature } MonthDay <br /> Year <br /> T Pnnled/Teed Name r I p/ / <br /> d:� t <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> (Generators who submit hazardous waste for transport out-of-state, <br /> DTSC 8022A(1/99[ produce completed copy of this copy and send to'DTSC within 30 days.] <br /> EPA 8700-22 <br />