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State of California—Environmental Protection Agency <br /> Form Approved OMB Na 2050-0039(Expires 9 30 99) See Instructions on back of page 6 Department of Toxic Substances Coniroi <br /> Please print or type Form designed for use on ehle(12 pitch)typewriter Sacramento California <br /> UNIFORM HAZARDOUS I Generators US EPA ID No Manifest Document No 2 Page 1 Informahon the shaded areas <br /> is not required by Federal law <br /> WASTE MANIFESTj ; of <br /> 3 Generator s Name and Moiling Address A State Manifest Document Number <br /> T <br /> _ r <br /> " — r-rr 1—(-^ 1 - err 11" --r r - <br /> ] B State Generator s ID <br /> 4 Generator s Phone I 11'C 1 Isj=—r _ <br /> N 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID <br /> LO <br /> rb <br /> _ _ D Transporter's Phone r�16 ! /y <br /> r J t- �-�r it rrt}- �,5 ��.j . l 1 .J• 1 7 -}1-_74 <br /> 1 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID <br /> QF Tronsporter's Phone <br /> V 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Facility s ID <br /> H Facility s Phone <br /> =)!L. 5 - _ (916) 371-5747 <br /> Q12 Containers 13 Total 14 Unit <br /> LJ 3 1 US DOT Descnphon lmcludmg proper Shiopmg Name Hazard Class and ID Number( No Type Quantity Wr/Vol f Waste Number <br /> Z ° State 3= <br /> 223 <br /> 3 -' _" A EPA/Other <br /> N I A <br /> E b State <br /> CN N <br /> W E <br /> v R EPA/Other <br /> T c Stale <br /> a T <br /> m O <br /> R EPA/other <br /> Lu <br /> d State <br /> r <br /> Z <br /> w <br /> lJ EPA/Other <br /> LU <br /> V) A Additional Descriptions for Materials Listed Above) K Handling Codes for Wastes Listed Above <br /> ua <br /> � c d <br /> a <br /> O15 Special Handling Instructions and Additional Information <br /> FQ '1 VPL-7tS 7� it' T"y "T TaL^t''7 T, r �T_n _ <br /> y <br /> S _. <br /> Z 1\1 f Y��`]1� v.s.�� r fS��'ti�[�-�-•i 3 a^. ,. � s Jr- . •- j�i-•r.r., <br /> ZL <br /> 'ERCNCY ii(';'; (915) 371717 ' <br /> 16 GENERATOR 5 CERTIFICATION I hereby declare that the contents of this consignment ore fully and accurate)y described above by proper shipping name and ore clossihed packed <br /> Q marked and labeled and are in all respects in proper condihon 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 economic allyy <br /> A practicable and that I have selected the raciico6le method of Treatment storage or disposal currently available to me which minimizes the present and future ito human hepUh <br /> and the environment OR if I am°small quantity generator I have mode o good faith effort to minimize my waste generation and select the best waste management method that is <br /> ! available to me and that I con afford <br /> 0 <br /> } Printed/Typed Name Signature _ Month Day Year <br /> 1 V - tilt t rk + sl r l <br /> Z IS r J <br /> W T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> B Month Da Year <br /> 0. P, ited/Typed Name Signature y <br /> 11 <br /> W 5 <br /> P <br /> p 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> w E <br /> V) R <br /> Q <br /> V 19 Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I 20 Fac lir Owner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19 <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE <br /> DTSC 8022A 14/97) <br /> EPA 8700-22 a <br />