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State of California -Environmental Protection Agency <br />Form Apprpved OMB No. 2050-0039 (Expires 9-30-99) <br />Please print &, type. Form designed for use on elite (12 -pi writer. <br />O <br />W) <br />v7 <br />n <br />N <br />LO <br />00 <br />00O <br />O <br />Q <br />U <br />J <br />Q <br />U <br />Z <br />t– <br />C14 <br />O <br />00 <br />co <br />4CV <br />Q <br />O <br />ao <br />W <br />Z <br />US <br />_ .0 <br />LU <br />N <br />Z <br />O <br />U) <br />LU <br />Q <br />Z <br />O <br />F— <br />Q <br />Z <br />J <br />V) <br />F <br />Z <br />See Instructions on backs a 6. <br />9 Department of Toxic Substances �.ontrol <br />Sacramento, California ; <br />„ <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />EPA 8700-22 ' <br />To: P.O. Box 400, Sacramento, CA 95812 0400 <br />P <br />Generator's US EPA ID No Manifest Document.. <br />I. 2. Page 1 <br />Information in the shaded areas <br />UNIFORM t'IAZAR�®ins t } � �� _ <br />L� <br />a >, <br />_ � _ <br />�, <br />I <br />is not required by Federal low. <br />-r _ <br />WASTE MANIFEST f <br />of <br />3 Generator's Name andMallingAddress <br />'5 <br />. State Manifest Document Number <br />F04 a L T <br />N ! i <br />B.' State Generator's ID <br />A. Generator's Phone { C°N "'j <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. 'State Transporter's ID [Reserved.] <br />1 f L �-tn „a•.. Y `° „}' F �,s`<ii�1�tT�aauxt,&` '.l <br />.e -�' " r "�` ' ' – '• <br />D- Transporter's Phone <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID [Reserved.] <br />F. Transporter's Phone <br />9 Qegnated Facility.Nam nnd_SfteAddress " ` 10. US EPA ID Number <br />sf- <br />t. <br />G State facilityID <br />,211, b e . t 1,:_- ms. e 2V- tl�,,! if r`w a a t . <br />,s <br />- <br />t § ;A ti :'.t,.,..-sfl.- t ' Itn a <br />.. r - ._ . <br />H. Facility's Phone <br />` <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />14. Unit <br />No. <br />Type <br />Quantity <br />Wt/Vol <br />I. Waste Number <br />a <br />State <br />.f {J I b t c' f�'z ]�P d., Y" '"+[.... <br />$ps r y�� r3(� 5b --Y- r' •+ 4 <br />EPA/Other <br />G <br />3– <br />N C3 <br />Y °„n .-. clot wr $ f 4"+ '. x4x, a.7f �.. C 6,. w. s {.! bF 45 bY.m .° <br />8 <br />;/ <br />L S f' <br />N <br />6'. <br />State <br />E <br />EPA/Other <br />R <br />T <br />C. <br />State <br />O <br />EPA/Other <br />R <br />d. <br />State <br />EPA/Other <br />J. Additianal0ascriptions for Materials Listed'Above . <br />K.' Handling Code-,, for Wastes <br />listed Above <br />14, <br />b. <br />w. <br />d. <br />; .. _ <br />ec] <aa plngJnstFucJigns qnd faddrtignallnfocrrlahgn 4 , � <br />f <br />1 <br />16. GENERATOR's CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above 6y proper shipping name and are classified, packed, <br />marked, and labeled, and are in all respects in proper condition for transport by highway ptcording 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 />that I have the method treatment, or disposalcurrentlyavailable to future human health <br />practicable and selected practicable of storage, me which minimizes the present and threat to <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 />available to'me and that I can afford,? i <br />Printe Typed Name L <br />Signature _ ,�l <br />Month Day,.-- ear - t= <br />l <br />AfPf <br />17 runs orter 1 Ackapwleclement of Receipt of Materials � <br />RT <br />Pr nted/Typed Naf <br />M h DqYeararp <br />y <br />A' <br />GP_k 5�..N L. 6� 2 tb <br />a . . <br />_ <br />ji. > ^`� .,,•. <br />B <br />18. Transporter 2 Acknowledgement orRecei°t of Materials T <br />R <br />L <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />T <br />A, <br />C <br />L <br />I <br />20. Facili Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />EPA 8700-22 ' <br />To: P.O. Box 400, Sacramento, CA 95812 0400 <br />P <br />