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b C,{-/ )k P, ' <br />Ste" of California—Environmental Protection Agency J <br />.., arm ApprovedbMB No. 2050-0039 (Expires 9-30.94) See Instructions on back o ge 6. Department of Toxic Substances Control <br />Please'print or type. form designed for use on elite (12pikh - Sacramento, California <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document <br />No. 2. Page 1 • Information in the shaded areas <br />IWASTE MANIFEST a O Iia <br />is not required by Federal law.- <br />9 of ` <br />3. Gener rt andiling Ad <br />kitw1 .» .p•s <br />toin <br />r •4Nyi-J f <br />4. Generator's Phonekn ( +e <br />00 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />Q <br />V <br />Q <br />.. .. .. <br />9. Designated Faciility. Name and Site Address10. US EPA ID Number <br />(ozPC}kMsiS <br />StYpCES <br />tAO <br />1515 SCU-1 1 RIV^, , ,OAD wEST SAaWARMr CA 95691 " <br />CAD0440®3556. <br />12. Containers <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) No. <br />V <br />Z <br />13. Total 14 Unit <br />Type Quantity Wt/Vol <br />= <br />a. ♦ tfi S Rt i <br />'m <br />) <br />0 <br />N <br />b. <br />C? <br />E <br />f <br />5 <br />C. <br />® <br />W <br />R:-2; <br />� <br />d �. <br />to <br />a <br />„w <br />Q <br />v <br />Z <br />O <br />15. Special Handling Instructions and Additional Information f� ® �j ' o <br />;/ ®;, <br />z <br />FkNDTx-PS ~fir 40 T-JOM WF-A/SARA -ArED <br />AND Ute' TNICSrI VPR PPr. <br />,,, <br />• 71-5747 <br />. s <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by pioper shipping name and are classified, <br />Qpacked, <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 />V <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 <br />—� <br />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 />uturethreat <br />V) <br />threatto human health and the environment; OR, if I am a small quantity generator, I have made a good faitis effort to minimize my waste generation and select the best <br />waste management method that is available to me and that I con afford. <br />® <br />Printed/Typed Nome e Signature e. Month Day Year <br />�- <br />}} <br />ZR. <br />17. Trans iter 1 Acknowledge ent of Re ei t of Materials <br />UJ <br />A <br />Pri ted/Typed Name - . Signature Month Day Year <br />T Vali �u �v � 9 l Ito 191 q <br />W <br />o <br />0 <br />ve tL <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />w <br />RPrinted/Typed <br />Name <br />Signature <br />Month Day Year <br />U. <br />O <br />e <br />R <br />Ly <br />19. Discrepancy Indication Space <br />VF <br />A <br />Z <br />f <br />L <br />f <br />20. Facili Owner or 022rator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19, <br />T <br />Pri /Typed No talar <br />Month Day Year <br />! <br />DO NdT WRITE B W THIS UNE. <br />Yellow: TSOF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />DTSC -OMA (9/93) (Generators joWubmit hazardous waste for transport out-of-state, <br />� conjW copy of this copy and send to DTSC within 30 days.) <br />EPA, 000-22 produce _ <br />