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State of California—Environmental Protection Agency <br />Forts oDromed OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back ofdkiLge 6. <br />,Pl-ose print or type. Form designed for use on elite 112-p rifer. <br />f�+ <br />F'rmtedJTgyyped Najme ({ y 8 <br />rp 6 "w� <br />Signature f y f. <br />jl l Jn j' SS r <br />rotor's US EPA ID No Manifest Document, KW <br />w <br />T7. <br />UNJFORM -HAZARDOUS <br />N <br />Printed/Typed a r',!� r d <br />d <br />WASTE -MANIFEST <br />MonTh- Day s Yea) ' <br />"+4 <br />•S � i <br />3. Generator's Name and Mailing Address cif r-. t `.., £'f <br />'r <br />LU <br />sy <br />4' 704 <br />r <br />~ <br />w ,' K 'f ' <br />P <br />0 <br />rA <br />n <br />A. Generator's Phone ( , b f. -��} y.,,'..x , - t 4P, <br />Printed/Typed Name - <br />CV <br />Mo'nih Day Year <br />S. Transporter 1 Company Name - 6. USEPAID Number <br />'C $tate Tc'i l <br />Q <br />U <br />19. Discrepancy Indication Space <br />y i ' Y ,,.. 3t, # it . E41i <br />F <br />A <br />O <br />C <br />I <br />L <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E State Tr`at <br />120. <br />Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as.notedin Item 19.' <br />f Transport <br />< <br />Signature <br />Month Day Year <br />I <br />U <br />9. Desigtsatpd facility Name and Site Addre;s 10. US EPA ID Number <br />G $tate foc <br />'i <br />H Factbty's <br />Q <br />T T _.., <br />u_ <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />tU <br />No. <br />Type <br />a. <br />LA,ly t i i { `1. 3 4 i. 5 Y <br />f <br />E <br />is . : 2 0.1 0 n 1 ,5,..fQ`_., <br />CA <br />o <br />N <br />b <br />ao <br />E <br />ao <br />v AR <br />A 0. <br />o T <br />00 O <br />R <br />d. <br />w <br />N <br />Z <br />O <br />a_ <br />N <br />W <br />l <br />Q <br />15 Spec! I Handling Instructions cndldditwnal Informahon = ? •,'c.. :' r <br />t tt rr��'' F4 ,s7€^4 4 <br />�t� 4 4..�1_N y a,.. ,"t"• f <br />7 <br />Z <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by propership ing name and are classified, packed, <br />marked, and labeled, and am in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />If i am a large quantiy 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 economially <br />.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 hecalth <br />and the environment; OR, if I am a small quantity generator, I have made a good faith effod to minimize, my waste' generation and select the best waste management method that is <br />available to and that I can afford: ' �.. ' / <br />�r D Y <br />Department of Toxic Su6stan <br />Sacramento, California <br />2. Page 1 Information in the shaded areas <br />isnot required`6y Federal law. <br />of <br />Q <br />U <br />Z <br />F'rmtedJTgyyped Najme ({ y 8 <br />rp 6 "w� <br />Signature f y f. <br />jl l Jn j' SS r <br />qnt .ay ear- . <br />j G.. { y <br />w <br />T7. <br />:Transporter I Ack owled ement of Receipt of Materials <br />N <br />Printed/Typed a r',!� r d <br />d <br />Sig a�g� B j <br />- ^l%.i.' <br />MonTh- Day s Yea) ' <br />"+4 <br />•S � i <br />I Ifi %°44,.e.�0[y{ <br />.. �ti �" / / <br />....me <br />'r <br />LU <br />S <br />4..-^',!`� <br />d <br />~ <br />U_ <br />P <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials � <br />T <br />Printed/Typed Name - <br />Signature - - - <br />Mo'nih Day Year <br />LU <br />N <br />E <br />R <br />Q <br />U <br />19. Discrepancy Indication Space <br />Z <br />F <br />A <br />C <br />I <br />L <br />120. <br />Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as.notedin Item 19.' <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />I <br />Y <br />i I i I <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) <br />EPA 8700-22 <br />Yellow: GENERATOR RETAINS <br />