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State of California—Environmental Protection Agency ` �'' " 1, <br />,FormiApproyed OMB No. 2050-0039 (Expires 9-30.99) See Instructions on backge 6. Department of Toxic Su6stances Control <br />Please point or type.- Form designed for use on elite (12-pitcak"riter. st Sacramento, California <br />r DTSC 8022A (1/99) <br />EPA 8700-22 <br />DO NOT WRITE BELOW THIS LINE. <br />Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />To:: P.O. Box 400, Sacramento, CA 95812-0400 <br />1 • enerator's US EPA ID No Manifest Document Na: <br />2. Page 1 <br />Information in the shaded areas <br />I <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />t�tit� 1�t x� 1 <br />of <br />is not required by Federal law. <br />3. Generators Name and Mt]ailing-Address L ¢, ') I ?'>2 tom- _: '17 4'< <br />A. State Manifest Document Number <br />r-•^ ��°°-^gp "° +i-, -:"' <br />B. State Generator's ID <br />4. Generator's Phone { 0151 -3 r` a' 81 <br />5. Transporter 1 Company Name ` b. US EPA ID Number <br />C. State Transporter's ID [Reserved.] <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; Desi noted Fa iliity.gr;negand.S t �ddreas g {" 10. US EPA ID Number <br />.., E ... fA'rm 1�.j.�.1's` a"t. IS.L J <br />G. State Facility s ID _ g <br />I01 �- tr mF�.��Fth'e <br />g�S <br />�y <br />FA <br />Facility's Phone <br />209 5,45-101"1 <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 />" <br />I: Waste Number <br />No. <br />Type <br />a Ir _ (_� yeI�G D, 1 S <br />� <br />l< <br />-State <br />.r <br />e si"/A .1 r €yyi9����$'^^ '#^:-�.'S�'t>�r,°;�:1-� }•01*_ t�ra^s^tr�---r4}.i" � t" Yy l� pgi. C.7 ' tta,--"�t•�t. ,t <br />t� <br />�) <br />EPA/Other <br />G <br />,.'�i a.:i...si-] 8` AR I. WASHER -SO LiT I N L _ 94 i. Vi t[ . � <br />14. <br />lv ✓ ! <br />E <br />N <br />b, <br />State <br />E <br />EPA/Other <br />R <br />Tt. <br />State <br />P K�Other <br />R. <br />d. <br />State <br />EPA/Other: <br />J; Add itional;Descrfptions far ivia4erials'I isted;Above . <br />K. Handling Codes for Wastes <br />Lister] Above' <br />a <br />b: <br />e. <br />d; <br />5- S c) 1, a ling nstt c gnSR (�cid�t nal f r 4110 �.. < <br />?BLit}? . �t' "a 6 24 i'arR <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 />marked, 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 pro ram. in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br />have treatment, disposal to the future threat to human health <br />practicable and that I selected the practicable method of storage, or currently. available me which minimizes present and <br />Arid the' environment; OR, if I am a small quantity generator, 1 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 1 can afford:- <br />Printed/Type a <br />Signature d " Jp a tonih Day / Year <br />B 0 <br />T <br />17. Trans orter 1 Acknowledgement of.Receipt of Materials <br />Printed/Typed Name <br />Sign re �f mf <br />��/ <br />Monti Day Year _r <br />t <br />J <br />P <br />B <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed.Nome <br />Signature 1`' <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space` <br />F <br />A <br />C <br />L <br />— <br />I <br />c:Owner or O orator Certification of recei t of hazardous materials covered b this manifest exce t as noted _ <br />in Item 19.Name <br />rdrinle/Typed <br />Signature <br />Month Day Year <br />r DTSC 8022A (1/99) <br />EPA 8700-22 <br />DO NOT WRITE BELOW THIS LINE. <br />Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />To:: P.O. Box 400, Sacramento, CA 95812-0400 <br />