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State of Colifornia—Environmental Protection Agency <br />form Approved OMB No. 2050-0039 (Expires 9-3494) See Instructions On back ®f ' 6. <br />'Please print or type. Form designed for use on elite (12 -pitch) Ator. <br />UNIFORM HAZARDOUS 1. enerator's US EPA ID No. Manifest Document 2. Page 1 <br />FEST <br />WASTE MANI®' of <br />3. Gene or's an ailing Ad <br />i�A t� X J <br />Department of Toxic Substances Control <br />Sacramento, California <br />Information in the shaded areas <br />is not required by Federal law. <br />in <br />$$vN1-1t- °Jc' <br />to <br />CV <br />5 <br />4. Generators one ('� "� <br />kn <br />565 <br />6 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />O <br />j <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />U <br />Q <br />CO Z <br />Facilitty�N�a7mge andSiteAddress (Vr;e 10. US EPA ID Number <br />9. Designated Facility <br />'(�A1fFlos T?:@ _' 1�AL!1?.!s;_S AITAL_W w7P_ R L. PS <br />o <br />1 515 4 -1 RIV.PR ROAD wasr SACPnt <, :'3, cA 95691 <br />. Q <br />CAT)043556 <br />U <br />Z2. <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />No. <br />Type_, <br />13. Total <br />ntity <br />QuaCD <br />14. Unit <br />Wt/Vol <br />3 <br />. <br />G <br />` `r c <br />0 A 1. V c` O u ( ` c % I <br />, <br />TIT <br />cv <br />0 <br />E <br />N <br />b. <br />ao <br />E <br />N <br />R <br />S <br />T <br />c• <br />0o <br />O <br />09 <br />R <br />Z <br />d. <br />W <br />Ug <br />LU <br />in <br />O <br />a <br />N <br />W <br />4 <br />Z15. <br />Special Handling Instructions and Additional Information <br />P <br />a <br />1-UNN 1T.P. S gr 40 HO(JR OSHA/SARA <br />Z <br />XND- 1)[SM, TITIC19H APP 4 D PPT`. <br />W <br />371-5747 <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, <br />—o <br />4 <br />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 />U <br />J <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 />—+ <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 />4 <br />N <br />threat to human health and 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 <br />waste management method that is available to me and that I can afford. <br />® <br />Printed/Typed Name ® <br />Signature p <br />Mo Day Year <br />Za <br />17. Transporter 1 Acknowledgement of R ei t of Materials <br />W <br />A <br />Pri ted/Typed Nam <br />V <br />Signature <br />Month Day Year <br />W <br />P <br />U Y1�eL JY <br />r <br />0 <br />18. Trans orter 2 Acknowledgement of Receipt of Materials <br />W <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />U. <br />p <br />E <br />R <br />W <br />19. Discrepancy Indication Space <br />Q <br />U <br />A <br />Z <br />_ <br />I <br />1 <br />20. FacilityOwner or O rator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19. , <br />T <br />Y <br />fPrinte /Typed Nome <br />Y <br />Signature <br />Month Day Year <br />v <br />DO NOT WRITE BELOW THIS LINE. <br />Blue: GENERATOR SENDS THIS COPY TO DISC WITHIN 30 DAYS. <br />DTSC 8022A (9/93) To: P.O. Bo 400, Sacramento, CA 95812-0400 <br />EPA 8704--22 <br />` j <br />