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Staab-of California—Environmental Protection Agency <br /> Form Approved OMB No.2050•-0039(Expires 9-3096) See Instructions on back o e 6. Department of Toxic Substances Contra <br /> Please print or type. Form designed for use on elite(12-pitch liter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> y is not required by Federal law. <br /> WASTE MANIFEST /J 1191 ! 113911 l. �` of <br /> 3. Generator's Name and Mailing A dress <br /> Ln 4 <br /> LO 34 3 Sa So/�,Q "no c Y 4) // } <br /> C14 4. Generators Phone 2y/' !: .3 ` /t J'L1 /f Gt t ? , �Y...% .s/ 4 <br /> 5. Transporter 1 Company Name 6. US EPA 11Y Number <br /> J <br /> —' 7. Transporter 2 Company Name 8. US EPA ID Number <br /> Q <br /> U <br /> 'r^"Q <br /> Z 9. Des,i.ggnated Facil'ty Name and Site Address 10. US EPA ID Number <br /> 00 k 2C}4SGr1..Ln . <br /> M 0 255 Parr B1t.YJ. <br /> ,y <br /> �yy?a <br /> co U J 12. Containers 13. Total 14. Unit <br /> Z 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. T Quantity Wt/Vol <br /> T <br /> � <br /> a.�H ikN--P.1:PA Eil2'.:3ri:Ok:.:; <br /> 3 <br /> C;; E Warr& En pt-'y Storage Tat* ,^, �� T P .01,'j q cl dP <br /> Sao N b. <br /> v E <br /> IT R <br /> d A <br /> m T <br /> O <br /> -R <br /> W <br /> F- <br /> Z d. <br /> W <br /> U <br /> W <br /> N <br /> O <br /> a <br /> N <br /> W <br /> C <br /> J <br /> Q <br /> Z <br /> 0 15. Special Handling Instructions and Additional Information <br /> Q P.t:'t'lc an.tiav FrY:dlt 3C7f.1Z ,oc ;jf u-T?Zi t i-:-Cli sta h i r 11.at o hi-r' �v:Z�:inv --tl:.:�.m 1 <br /> Z �G? <br /> W /r J <br /> J 16. GENERATOR'S CERTIFICATION: I hereby declare chat the contents of this consignment are fully and accurately described above by proper shipping name and are classified, <br /> Upacked,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> I <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 1 have determined to be <br /> J <br /> iL 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 /> c!1 threat to human health 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 <br /> waste management method that is available to me and that I can afford. " <br /> O Printed/Ty7cme f p Signature Month I Day Year j <br /> U Y +ti ✓ vt� ) i { t 1 i �y� <br /> w g 17. Trans f Transporter 1 Acknowledgement of Recei bf Materials <br /> (� A Printed/Typed Nome T, Signature." � Month _Day •Year <br /> w s r ! f ,l > :fc:y.�' tri ,f. . / f9 <br /> P <br /> LU 0 18. Transporter 2 Acknowledgement of Receipt of Materia f <br /> LL T Printed/Typed Name Signature Month Day Year <br /> o E <br /> R <br /> LO19. Discrepancy Indication Space ' <br /> F <br /> A <br /> ZC <br /> _ I <br /> 1 20. FacilityChvner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC•8622A (1/95) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />