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;`'Stdte of CaliFornia—E^v'ro^mental Protection Agency See Instructions on back of 6. <br /> Foem Approved Omit No.2050-0039(Expires 9-30.99) Department of Toxic Substances Control <br /> Please prin,,or type Form designed for use on elite(12-pitch) er. <br /> 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 Iof <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> 511199 <br /> O B. State Generator's ID <br /> nA. Generator's Phone <br /> CV 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> CP D. Transporter's Phone <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> QF. Transporter's Phone <br /> V 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility s ID <br /> Q7. <br /> --j Z H. Facility's Phone <br /> O <br /> — 12. Containers 13. Total 14 Unit <br /> s Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> Ra V No. Type Quantity Wt/Vol I. Waste Number <br /> Z a State <br /> EE <br /> F= EPA/Other <br /> G '1 t <br /> oE 6 State <br /> 00 <br /> cooE <br /> 4 R EPA/Other <br /> C14 <br /> A <br /> O T State <br /> 00 ® EPA/Other <br /> R <br /> t- d. <br /> State <br /> H <br /> Z <br /> V EPA/Other <br /> w <br /> U) J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> 0 a. b. <br /> a <br /> N <br /> W <br /> C. d. <br /> a y <br /> Z <br /> 0 15. Special Handling Instructions and Additional Information <br /> Q <br /> Z <br /> w <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 /> practicable and that 1 have selected the racticable method of treatment,storage,or disposal currently available,to me which minimizes the present and future threat to human health <br /> N p <br /> 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 /> CiI can afford <br /> 0 available to me and that <br /> �. Printed/Typed Name Signature _ .,Month Day;" Yea <br /> J <br /> _ ✓ 0j <br /> — T17. Transporter 1 Acknowledgement of Receipt of Materials <br /> U.1 p Printed/Typedm <br /> Nae,. s Signature' _. Moth Day"> Year j <br /> LLJ <br /> LL. 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> T Printed/Typed Name Signature �{ Month Day Year <br /> a �. ... <br /> E`— y _a_ r i- <br /> V 19. Discrepancy Indication Space <br /> Z IF <br /> — A <br /> C <br /> L <br /> 20. F cility 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 /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> L. <br /> DTSC 8022A(1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />