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State of California—Environmental Protection Agency - f'et'e'`d.`'i <br /> "ved OMB No.2050-0039(Expires 9.30-99) See Instructions on back of 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite f 12-pitch) ter. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS { r4i �y.r �a ����m � $ d��, , > ,� is not required by Federal law. <br /> WASTE MANIFEST of <br /> 3. Generator's Name and Mailing Address ir•�, - - -; } i.......:.. A. State Manifest Document Number <br /> ,3,4 �"�CI`-H rt!A� D 24490526 <br /> P=AT1`+#: i .m'al`t,. l-: ADOM I N <br /> O L.A d i,iR f.P C,et 9 y ,3 } B. State Generator's ID <br /> r.�A,( t <br /> dg Iii r$,7i L,A—3. : i.' <br /> to 4. Generator's Phone (:':••:» ) <br /> N 5 Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.j <br /> to f, <br /> Fa <br /> ; . t .. .. ., ? lJ ?a�" /v <br /> D. Transporter's Phone <br /> �CP800 369 � fps <br /> ._.-Transporter-2 Company Name B. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> F; Transporter's Phone <br /> a V ,9atgd Fp i i Ila a and•, i}p A d e s. 10. US EPA ID Number G. State iJ <br /> $� t ' a`'�a sir s �., '! 4 � C)LV 0 <br /> 1 9 <br /> ¢}. <br /> BA1.. +:A r .1,:� ','Cx f �v.�!a F��s J��!.�i� }. H. facility's Phonel�o 0 545-1011 0$$ <br /> U_ <br /> Q 12. Containers 13. Total 1A. Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> U No. Tye Quantity Wt/Vol I. Waste Number <br /> Z is-BEE, t�.;LE-A4�E�S''#c:r 'tµ#Ne"i 1ha ;'"r i' . t" xw< r i.it state 1'4 <br /> L i of s T i c .Ner.3f! f F`)d tJG F'A �:� v'�'ta d�§ ( ..�. ? � ` EPA/Other <br /> 'G AOWECIIIJ�; '111 A <br /> o N b' ware <br /> 00 <br /> co <br /> oR ry+c EPA/Other <br /> tiO4 A C N)` State <br /> T K0 <br /> OD O "qc::z <br /> R ell14 EPA/Other <br /> Ce d. A,t State <br /> Z <br /> LU EPA/Other <br /> V i L <br /> LU 7 <br /> (A) K Additional Descriptions far Mafertols Gsled Above € K. Handling Codes for Wastes Listed Above <br /> Q .`a �. r� b € t� F d� b <br /> h <br /> W <br /> oC C. d. <br /> Q95 190 t k <br /> 1 I��ppnddjj,�r�g In uyG p p �cl taona[I 4rmatipn, 1`�, , " <br /> �.�� .» •.'t�.�.i'tidv 7 �"iM�7t"'s C...?�,F""tl�>,r'"-_1 f ��s c l"'[�X <br /> Q <br /> Z <br /> 2 i. <br /> H <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 /> Umarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> J If I am a large quonti 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 economicall <br /> � ty <br /> a practicable and that I hove selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human healt <br /> V) 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 waste management method that is <br /> W 1`available to me and that I can afford. <br /> O <br /> Printe typed Nam@ Signature } r / Mopth. D Yeor— <br /> w <br /> (.D T 17, Tran -Iter 1 Acknowle ement of Receipt o Materigls <br /> W ature <br /> R Printed/Typed Name /:' t / f�n / Mont Year. <br /> LLJ <br /> W 0 18. Tran rtei^ cknowled ement of Receipt of Materials jr <br /> T Printed/Typed Name Signature Month Day Year <br /> w E <br /> H R <br /> Q <br /> („) 19. Discrepancy Indication Space ' <br /> Z F <br /> A <br /> C <br /> L <br /> 1 2 F ility Owne or Operator Certification o0rekeipt of hazardous materials c ve d by this manifest except as notid in Item 19. 0 <br /> T W- 0 <br /> Si atu e t r on0D Yam <br /> Y !;`' <br /> NOT WRITE BELOW THIS L NE. <br /> Yellow: TSDF SENDS THIS COPY,_ )ERATOR WITHIN 30 DAYS. <br /> DTSC 8022A(1/99) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />