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,State of-Col ifornia—EnvPronmental Protection Agency <br /> Forrr'AKiroved 9MB No.2050-0039(Expires 9-30-99) See Instructions on beak o$ 6. Department of Toxic Substances Control <br /> Please print 6r type. Form designed For use on elite(12-pitch) er 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 of <br /> 3. Generator's Name and Mailing Address ]"` j ` A. State Manifest Document Number <br /> 23473023 <br /> O i B. State Generator's ID <br /> LO <br /> LO 4. Generator's Phone <br /> CV 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> LO <br /> W ; r i D, Transporter's Phone <br /> 1 J <br /> O <br /> 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> Co 7. Transporter 2 Company Name <br /> r <br /> J F. Transporter's Phone <br /> Q G: State Facnhtx s ID <br /> V - 10. US EPA ID Number <br /> 9_..Designated Facility blame and.Stte Adcfres! <br /> Z <br /> , <br /> z.! H. Facility's Phone <br /> LL- <br /> Q12.Q 12. Containers 13. Total 14. Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol L Waste Number <br /> V <br /> State <br /> a <br /> Z ;. *, Z ,g ! zf G t: _ <br /> EPA/Other <br /> State <br /> o E N b, <br /> 0 E EPA/Other <br /> v R <br /> V A C stare <br /> o T <br /> C O EPA/Other <br /> R <br /> C d. State <br /> I- <br /> Z EPA/Other <br /> LU <br /> V <br /> u tK. Handling Codes for Wastes Listed Above <br /> L') J. Additional Descriptions for Materials Listed Above <br /> Z a. b. <br /> O ` <br /> a <br /> WC. <br /> d <br /> o< <br /> J <br /> 15 S ecial Handling Instructions and Additional Information i - - - <br /> P 9; 1 _ti Y <br /> Q <br /> Z <br /> w <br /> 2 <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 economically <br /> a practicable and that I have selected the practicable method of treatment,storage,orisposal 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 16 minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford. </ <br /> O f r- Month, Day Yeah <br /> Prm��d/Typed Name Sig Vfe r` f t� <br /> r' <br /> in f� � <br /> Z ��_ w Fw".t <br /> w T _.- _ S <br /> -1' Transporter cknowled amen)of Recei t o}•dJlptena(3r <br /> A/ .` f.�^ 51 4nafure �` i}l f -.Day E Year,^ <br /> R, ,A„ f <br /> Mon 1 C <br /> LU .� Pnnted Tie am <br /> w <br /> O p <br /> 18. Trans orter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed Ndine Signature Month Day Year <br /> T n <br /> LU E <br /> t� R <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> L <br /> 20. FacililyOwner or Operator Certification of recei t of hazardous materials covered by.tbis manifest except as noted in Itemj 9. <br /> / D Year i <br /> T Printed/Typed Name i 9 ature r �` fF t aYr �r <br /> Si n rpJ, <br /> Y cy, �T fl t `�•'tom'• �r <br /> ' f A <br /> ff, <br /> 1. <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 />