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I State of California—Environmental Protection Agency <br />corm Appra4ved OMB :Nc.'2050-7t039 (Expires 9-30-99) See Instructions On back (&ge 6. <br />Form designed for 12 <br />Deportment of Toxic Substances Control <br />Please print <br />or type. use on elite f -pitch/ .,, ewriter. <br />Sacramento, California <br />UNIFORM HAZARDOUS <br />1 Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />is not required by Federal law. <br />WASTE MANIFEST <br />I �. / <br />of <br />3. Generator's Name and Mailing Address <br />I q <br />&a <br />ko <br />A. Generator's <br />one <br />CV <br />5. Transporter 1 Compa ante 6. US EPA ID Number <br />SM, <br />ap <br />CP <br />7. Transporter 2 Company Name 8. US EPA ID Number° <br />J <br />Q <br />U <br />� <br />9. Designated Facility Name and Site Address 10. US EPA ID Number` <br />°SOS <br />g <br />ENV Mr-NMENTAL <br />Lo <br />�, <br />1 15 I RI ROAD, ''ivTST 53,ACM � T -I ` " l -35691 <br />o <br />$$._ <br />Q12. <br />U <br />11 . US DOTwDescripti,Ro�,n�(including Proper Shipping Name, Hazard Class, and ID Number( <br />Containers <br />13.Total <br />Type Quantity <br />14. Unit <br />Wtl <br />/V <br />No. <br />- Z <br />a. <br />wtl <br />mit t +odda" <br />�� 1 ` I �." 1% 4S 4et�y ` J� ` � �' � --'.i� <br />s^s <br />i <br />V <br />i�diy✓ 9�'�1� <br />� <br />i 1 <br />va <br />'� r` <br />`� <br />a6'. <br />N <br />o <br />E <br />N32W <br />b.- <br />W-11MI, ' <br />00 <br />E <br />c <br />R <br />A <br />o <br />T <br />O <br />co <br />R <br />w <br />d. <br />Z <br />LU <br />� <br />s <br />Uj <br />t4 <br />Mr <br />(t <br />' <br />Q <br />r <br />Z <br />Q <br />15. Special Handling Instructions and Additional Information <br />VSA�IA 74 <br />W <br />eZ c7 <br />AND' USA['A FROS' I-1 <br />+. <br />ggq} T <br />s''.4 Y CONTACT: (AAV) 3ipyy—w$44 <br />Vmarked, <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, packed, <br />and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />—J+ <br />If I am a large quantity generator, I certify that I have a progyram in place to reduce the volume and toxicity of waste generated to the degree <br />I have determined to be economically <br />Npracticable <br />and that I have selected the practicable method of treatment, storage, or disposal currently ovoi able ro me which minimizes the present <br />the OR, if I I have faith best <br />and Futuro threat to human health <br />is <br />ce <br />and environment; am a small quantity generator, made a good effort to minimize my waste generation and select the <br />available to me and that I can afford. <br />waste management method that <br />} <br />Printed/,Typed Name <br />Signature' f- a <br />P'r <br />Month... Day sear _ <br />Z <br />`' irk' 1 rdr " j� <br />R <br />17. Transporter 1 Acknowledgement of Receipt of Materials k p <br />wB <br />Printed/Typed <br />Name r d <br />Signature ." 'i } f t ${ r '' <br />Month Day <br />p�Year <br />u. <br />0 <br />1 A. transporter 2 Acknowledgement of Receipt of Materials <br />TPrinted/Typed <br />Name <br />Signature <br />Month Day Year <br />w <br />V) <br />E <br />R <br />Q <br />U <br />19. Discrepancy Indication Space <br />Z <br />F <br />A <br />C <br />I <br />L <br />20. Foci Owner or Operator Certificc on rdcei t drdi mmf9sria rork"er b ,this manifest except as noted in Item .19. <br />T <br />Printed/Typed Name <br />, I a <br />ignature f <br />Mon�f Dayr Year <br />e t ,- <br />DO NOT WRITE BELOW THIS LINE. ' <br />DTSC 8022A (4/97) <br />EPA 8700-22 White: TSDF RETAINS <br />