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State of California—Environmental Protection Agency <br />' Form Approved OMB No.2050-0039(Expires 9-30.96) See Instructions on back ge 6. Department of Toxic Substances Control <br /> Please print or.type. Form designed for use on elite j 12pN writer. Sacramento,California <br />? 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> r UNI RM HAZARDOUS 7 is not required by Federal law. <br /> WASTE MANIFEST of <br /> 1 <br /> A. Generator';.Name and Mailing Address A. State Manifest Document Number <br />! LOG �S 3 -T d �?" <br />( ^ T��'7� B. State Generators ID <br /> 00 4. Gener fotor's Phone <br /> I0 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporters ID <br /> �f SUi"Lw•'a a:O'dPie s1iBk. :C T��.SER ICESCD Tr rter's Phone <br /> J <br /> AD 9 6 9 5 7 1 °nspa (510)l 9Q>> <br /> J <br /> Q 7. Transporter 2 Company Name 8. US EPA ID Number E. State:Transporters ID <br /> U <br /> i F. Transporters Phone <br /> E Q <br /> Z 9 Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> o C 7 t <br /> MCT J }t H. Facility's Phone <br /> (510)M44100 <br /> C,awf uOJ C JA P 19 18 10 188 17 14 11 13 <br /> U <br /> Z 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number 12• Containers 13. Total 14. Unit <br /> LO P ( 9 p PP 9 ) No. I Type Quantity Wt/Vol L,YYaste,Ntimber - <br /> State <br /> c:; NUN -i.CsRA i'�rt�,�RGGUS'WP.STEE,LIQUID 0 0 1 T 1T EPA/Other, <br /> i co N b. state <br /> CN R EPA/Other <br /> 1 A State <br /> i 0 T C. <br /> r <br /> R I EPA/Other <br /> w <br /> t � <br /> s <br /> Z d. State. <br /> LU <br /> WEPA/Other <br /> t.. N <br /> • <br /> Z <br /> 0 J. Additional'Descriptions foe.Materials1isted Above: , - K. ondling Codes for Wastes Listed Above <br /> a. b"" <br /> w <br /> 9iy J <br /> C. d. <br /> O <br /> 15 S ecial HandlingInstructions and Additional Information <br /> Z )Y.. <br />' w ..:gg 3iJ0 gp <br /> t <br /> 1 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, <br /> t <br /> U packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> 4 <br /> fJ 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 <br /> p economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br />} W threat to human health and the environment; OR, if I am a sma!I quantity generator, 1 have made a good faith effort to minimize my waste generation and select the best <br /> Ce waste management method that is available to me and that I can afford. <br /> o PrintecUTyped Name Signottyev`1 Month ` Days Year <br /> >- �- <br /> 1 U �'`r� i S 1rt � r.; 1 { <br /> Z T 17. Transporter 1 Acknowledgement of Receipt of Materials / <br /> p w R <br /> (D A Printed/T ped Name Signature a i' Month Day Year <br /> CX <br /> S j <br /> P 18. rans iter 2 Acknowled ement of Receipt of Materials w R <br /> O T Printed/Typed Name Signa re Month Day Year <br /> E <br /> R <br /> N19. Discrepancy Indication Space <br />} Q F <br /> fYf UA <br /> t Z C <br /> I <br /> L <br /> 1 20. FacilityOwner or Operator Certification of receipt of hazardous materials cevered by this manifest except as noted in Item 19. <br /> TY ' ted/ ped Signa4u� /ASonth DayJ 1 ea` <br /> 7i <br />! DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (9/94) <br /># EPA 8700-22 <br />