Laserfiche WebLink
State of California—Environmental Protection Agency <br />Form Approved,OMB No. 2050-0039 (Expires 9-30-99) See Instructions On back Of b. Department of Toxic Substances csntrol <br />Please print or type. Form designed for use on elite (12-pitch) er. Sacramento, California <br />��— <br />1. erator s US EPA ID No. Manifest Document No74W <br />Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />�`' <br />isnot required by Federatlaw. <br />WASTE MANIFEST`g" <br />`� <br />of <br />3 Generator's Namgg,e. and Mailing Address <br />A. State Manifest Document Number <br />_ <br />225271;32, <br />- - . <br />S. Stdte Generator s'ID <br />V) <br />N <br />n <br />4. Generator's Phone (. - ). _ i, <br />N <br />5. Transporter -1 Company Name - - -. - 6. US EPA ID Number <br />'C. State Transporter's ID [Reserved.] <br />to <br />D. Transporters Phone <br />O,xJ <br />�^ <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. Slate Transporter's ID [Reserved.] <br />I� <br />I <br />F. Transporter's Phone <br />Q� <br />I V <br />G. State Facility s ID <br />I <br />w <br />-9Designated Fac ity Name and Site Address, 10. US EPA ID Number <br />�� <br />H, Facility's Phone <br />ti <br />IQ <br />u <br />tu. <br />�Q j <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />I. Waste Number <br />No. <br />Type <br />Z <br />a <br />State <br />. b <br />... <br />.; <br />,t <br />J r <br />t s <br />i"' ,cfi e j z` �, t %e=" ' <br />EPA/Other <br />.... . ., It . ,_ <br />..: ,.I..._f..#t,J� . F'{ .-.> i.� <br />o <br />EN <br />b, <br />State <br />6 <br />E. <br />EPA/Other ' <br />v <br />R, <br />A <br />C. <br />State <br />o <br />T <br />00 <br />® <br />EPA/Other' <br />R <br />LU <br />d. <br />State <br />Z <br />EPA Other �' <br />LU <br />U <br />- <br />LU <br /># Ac]diteonalflescriptionsforMateriglslrsted.Akova <br />K'HpndlmgCodasFor`Vasles'GistaAbove'.' <br />Z <br />O- <br />a • <br />a. <br />04 <br />t <br />V <br />0- <br />u <br />hw)sp d Addinal�infol ation <br />15� jpeciolJlshFlRglnstrytttb �t <br />Q <br />tY ., 3 ii ,. .. 4 <br />Z <br />LU <br />R. .._ <br />F-• <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully apd accurate described above by proper shipping name and are classified, packed, <br />Umarked, <br />and labeled and are in all respects in proper condition for transport by highway according to applicable international' and national government regulations. <br />J <br />have waste to the degree I have determined to be <br />0- <br />If i am a large quantittyy generator, I certify that I a program in place.to reduce the volume and toxicity of generated economically <br />that I have selected the racticable of treatment; storage, disposal currently available to me which minimizes the and future threat to human health <br />practicable and p method or present <br />and the environment; OR, if I am a small generator, f have made a good faith effort to minimize my wad +ste generation and select the best waste management method that is <br />Q <br />quantity <br />available to me and that I can afford. <br />OPrinted/Typed"Name <br />Signature <br />Mo the Day6. Year -} <br />Y / <br />T <br />i=17, Transporter 1 A k nowled ement of Receipt of Materials il <br />LU <br />p <br />f <br />Printed/TypriN me Z, f l Signet "` tr ^- _ <br />Mfonth€' Dayr: <br />! <br />Year % <br />LULU <br />} <br />w <br />u <br />(P) <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />d <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />w <br />E <br />R <br />Q <br />V <br />19, Discrepancy Indication Space <br />z <br />a <br />1. <br />20. ocility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />f <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) Yellow: GENERATOR RETAINS <br />EPA 8700-22 <br />