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State of Coliform* --Environmental Protection Agency <br />*Form Approved'OMB No. 2050-0039 (Expires 9-30.94) See Instructions OA back Of4 <br />Please print or type. Form designed for use on ofite (12-piRrh) <br />is UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. <br />WASTE MANIFEST A cil it ioo(o[2vol <br />3. Genet is and ailing Ad sy[®hkt� s -J <br />o al`�x af► 1 �•, <br />P � � a• �• T�•a wf f l'e Av c :- . <br />his A�( �-� R 33 <br />h 4. Genet or s one ( tr9A 3 i <br />16 <br />1 d 5. Transporter 1 Company Name 6. US EPA ID Number <br />O <br />J <br />J <br />V <br />s Q <br />Z <br />O <br />sZ <br />CYI) = <br />N E <br />0 N <br />0? E <br />CSV R <br />A <br />T <br />e R <br />ce <br />Z <br />S U <br />7. Transporter 2 Company Name <br />8. US EPA ID <br />-Designoted Facility Name and Site Address <br />10. US EPA ID Number <br />6. <br />Department of Toxic Substances Coni <br />tie WRIN, V 'I',, '] i ""I <br />Sacramento, California <br />Z <br />2. Page 1 . <br />Information in the shaded areas. <br />is not required by Federal law <br />9 of <br />-Designoted Facility Name and Site Address <br />10. US EPA ID Number <br />i ii 11 ON <br />NO <br />tie WRIN, V 'I',, '] i ""I <br />Special Handling Instructions and Additional Information ® "�4 <br />Z <br />unng� n Trr�ee?sS T!I2 4rt?7�Ti' E 00'"WSAaA T-RAV'IED <br />et e <br />LIJ <br />ZMERCOM 71-5747 <br />I.- <br />1 <br />16. GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, <br />4 <br />Mil-IFfl'Nbi�c.'£"F1''£`4a•'Pa%ar:��`"''YRea'.a��."Y'l. <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 />11. US DOT ►_ , <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 />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 />CL <br />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 />V) <br />waste management method that is available to me and that 1 can afford. <br />QjPrinnttred/Typed <br />Name a Signature v Month Day Year <br />?- <br />g^ <br />L1.eQ 1(' 1-° <br />TT <br />17. Transporter 1 Acknowledgement of R ei t of Materials <br />Z <br />Lu <br />b. <br />C. <br />N <br />Q <br />i ii 11 ON <br />Z15. <br />Special Handling Instructions and Additional Information ® "�4 <br />Z <br />unng� n Trr�ee?sS T!I2 4rt?7�Ti' E 00'"WSAaA T-RAV'IED <br />et e <br />LIJ <br />ZMERCOM 71-5747 <br />I.- <br />16. GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, <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 />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 />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 />CL <br />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 />V) <br />waste management method that is available to me and that 1 can afford. <br />QjPrinnttred/Typed <br />Name a Signature v Month Day Year <br />?- <br />g^ <br />L1.eQ 1(' 1-° <br />TT <br />17. Transporter 1 Acknowledgement of R ei t of Materials <br />Z <br />Lu <br />n <br />s <br />Printed/Typed Name ,p Signature o Day Year <br />VtM �u 1V1 IV <br />IX <br />i <br />0 <br />/ i 1%�e 2L <br />18. Trons r 2 ledgement of Receipt of Materials <br />W <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />Ili <br />O <br />E <br />R <br />Lu <br />19. Discrepancy Indication Space <br />F <br />U <br />A <br />Z <br />_ <br />1 <br />t. <br />I20. <br />Facili Owner or Operator of receipt of hazardous materials cove b this manifest except t as red in Item 19. <br />T <br />Y <br />Prin /Typed Naze %7/1� 1pru <br />UJQCertification <br />t�0/ iA • <br />Day Year <br />r� <br />91 <br />DO Nil WRITE 860W THIS UNE. �- <br />a' Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />m <br />" <br />DISC 8022d' (9/93) (Generators bmit hazardous waste for transport out-of-state, <br />' DISC 30 days.),.: <br />this <br />EPA. 8700-22 produce comil copy of copy and send to within <br />