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Stem ff ^ AM <br />Form Approved NO. 9 (Expires 30.96) S" Inshwflons on back of 6. Department of Toxic Subolances Car" <br />Please PrW or type.' Form desknod forum an aft (12wkh) A w Sacramento, Calliorwal <br />DISC 9022A (9/94) <br />EPA 8700--22 Yellow: GENERATOR RETAINS <br />1. Gentralor's US EPA ID No. Manifest Document No. <br />UNW*W HAZARDOUS <br />2. Par I <br />Inforawtian in the shaded ansm; <br />is not requited by Fft%#W law. <br />WASTE MAMNST V, <br />1(li 01 '1 <br />I of <br />". t�� <br />3 Generators Nome 9nd Mailing Address <br />I A. State ManiFert DacumW Number <br />-A <br />a' State Q~ <br />Ito I I 10A1_ <br />4. Generator's Phone <br />IQUP <br />5. Trgasporter I Company Nam* 6. US EPA ID Nurnger <br />C. T sID <br />.7 <br />7. Transporter 2 Company Nome S. US EPA ID NuffAw <br />E. $**a T ID <br />F. T Ph.. <br />9, Des' ffVCF _tW. Site Address <br />tpg4af 10. US EPA ID N,,bdr <br />, �t <br />G_ State Fadlity's ID <br />q rr <br />H. Faadity'a <br />(5101235-1393 <br />t 2f r <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />0! <br />I. waft "w*w <br />No. <br />a. NC)N:ii_iA__Ra_zarx1ou3 Vftste Solid <br />_Igo <br />0"12 <br />WA4M <br />G <br />Waste rY%*y StotNo Tank. <br />T P <br />P <br />b, <br />E <br />A <br />T <br />C. <br />0 <br />d. <br />am,I <br />7 r <br />1 Ad"—) DmcdW.&_fr MAft"Is Lieted Above <br />I.. JDWIty oraW Taok(S) <br />K. Handling Codes for Wastes Wood Abw <br />b. <br />......,Tank(s) hove bem inertwi wiVi Ir <br />lbs,-Ilry Ice Per 1000 Gallce CVacity . t <br />d. <br />IS. Special Handling Instructions and Additional Information <br />K1?'_T._* ZWay ftcln SoUrC'e-S -,,f ignition. Alwav, w--ar harri-ots; 4im w -,villi r,-xn-I <br />U.G.S.T.'r, 24 Hr. Irontact <br />16. GENEIRAYOR'S CERT I hereby ddare that the contents of this consignment are fully and W-rc oly described above by pope, dripping name and aro li.WW, <br />packed, marked, and labeled, and are in all respects in proper condition for transport%y highway -cording to applicable international and national gervornawt regulations. <br />If I am ' large q—Mty 9"'WA 1 certify 0-0 1 have . program in place to reduce the volume and toxicity of ,,do generated to *,a dogma I have doWnWned to be <br />economically practicable and that I have selected the practicable method of treatment, stwage, or disposal currently avaik" to me which minimizes the provent and future <br />Murat to human heafth and the environment, OR, if I am a small quardity goroeratyf, I have -ads a good faith effort to minimize my wcate gorwalion cold 1010d Ow beat <br />was" manmetnent roollsod Mata available to me and that I can afford. <br />�R&Ied/Typed Nam <br />LP * <br />signc,14 67 <br />f <br />Month -140 <br />T11w <br />/ I v <br />T <br />17. Transporter I Acknowledoement of Receipt of majorich <br />A <br />N <br />Pr /Typed NowD01— <br />S*O <br />Year <br />S <br />6 <br />18. Tron-orter 2 Acknowledgement of Receipt of Materials <br />T <br />Printed/Typed Nome <br />Month Day yew <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />I <br />I <br />l <br />20. Facilily Owner or Ooorator Cerokation of receipt of hazardous materials covered by this manifest exceo as noted in horn 19. <br />T <br />Prkftd/Typed Nam Signature <br />Month Day Year <br />Y <br />DISC 9022A (9/94) <br />EPA 8700--22 Yellow: GENERATOR RETAINS <br />