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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9.30-99) See Instructions 098 back Of a 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite 11 2-pitch) er. Sacramento,California <br /> UNIFORM HAZARDOUS -nerator's US EPA ID No Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST is not required by Federal law. <br /> of <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> 0 <br /> O "_ B. State Generator's ID <br /> LO 4. Generator's Phone ( ,) <br /> 5. Transporter 1 Company Name <br /> LO6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> LO <br /> CP <br /> O D. Transporter's Phone <br /> O <br /> CP <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> ' Q F. Transporter's Phone .. <br /> "+±V 9. Desi noted Facili Name and Site Address <br /> 9 �Y _ J 10. US EPA ID Number G. State Facility's ID <br /> �gZ <br /> r;O {.:' H. Facility's Phone <br /> m ' <br /> a U 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Num6er) 12. Containers 13. Total 14 Unit <br /> Z a No. Type Quantity Wt/Vol I. Waste Number <br /> State <br /> r; t <br /> 3 G EPA/Other <br /> E <br /> CN <br /> 0 N 6 <br /> 85 E State <br /> N R EPA/Other <br /> v A C. <br /> T <br /> 0 ® SPate <br /> R I EPA/Other <br /> LU d, <br /> 1— <br /> Z State. <br /> U, <br /> V EPA/Other <br /> LU <br /> Z J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> a. 6. <br /> LU; <br /> - ! C. d. <br /> Q i <br /> Z i <br /> 15. Special Handling Instructions and Additional Information _s { t tt <br /> 1 _.. <br /> Q <br /> Z <br /> LU <br /> U—J+ 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurate)y 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 /> 1' 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 econlly <br /> N practicable and that I have selected the practicable method of treatment,storage,or disposal currently availabl o me which minimizes the present and future threat to human heaomicalth <br /> and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my'wva,to generation and select the best waste management method that is <br /> O available to me and that I can afford.f ' <br /> } Printed/Typed N e,�'� - j St�nature /f �f Montb� la,,-, Year <br /> w T i <br /> 3A <br /> R . 7. Transporter 1 A knowled ement of Receipt of, aterials <br /> w A/ Printed/Typedr✓+N.1ne <br /> ,✓- ( Sign tune yr.C^ __ Mo h pa 'ti Yeah r <br /> • �P <br /> _ <br /> W S�,. <br /> d " /' ''� J� %rte <br /> LL 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> T Printed/T.yped Name ture r'- <br /> LLJ E— .....,,.Y.nr '^.a„-„A„�.,d.,,,, S; O f i / / Month Day Year- <br /> 7 7- <br /> V 19. Discrepancy Indication Space J <br /> Z IF <br /> A �> <br /> L <br /> 1 20cility Owner or Operator Certification of recei t of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Prfnte /Typed meSg n h <br /> Y fure�' �E �) y Month Day Year <br /> DO NOT WRITE BELOW THIS LINE: <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A(1/99) (Generators who submit),z rdous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />