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St of Salifornia=Environmental Protection Agency <br />�rm Ap bved OMB No: 2050-0039 (Expires 9-30-94) SEE IIIIStrtJG4!®ID9 011 bdC1C O 9E 6. Department of Toxic Substances Control <br />I? ease pn or type. Form designed for use on elite (12pitcf�++riter. r ° Sacramento, California <br />1 • ;O • <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />DTSC 8022A (9/93) (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 />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 />jo <br />of <br />3. Generator's Name and Mailing Address <br />j°P► Q erfo IL?V W, —T%; C <br />d <br />�F <br />4. Generator's Phone 9i(a �vbl -3g (o( �7a 577�y„ <br />r�'t� cAs 9 � <br />� � atof��S , <br />�� <br />( ) ,� <br />ER11 <br />5. Transporter 1 Company Name b. US EPA ID Number <br />/" Q 2 <br />L4 <br />c.-6� c iAQ � � f / <br />Y <br />�� t <br />1 410. <br />7. Transporter 2 Company Name 8. US EPA ID NumberMEN <br />�fAFff2 ."_ <br />WN <br />9. Designated Facility Nome and Site,Addr ss 10. US EPA ID Number <br />66lM, No-tlq'if�erjicy':(ufA-£)-�� <br />4idla�U <br />_� <br />E <br />r 01I bQlf Priidt <br />rr <br />Sa o� a c r 3 1511 q R 10x8 <br />dN� 1,1 A -' _ A <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 />Wt/Vol <br />s <br />$ <br />No. T <br />a. �(� ON `� ��2�� <br />Q2ui'CF,,yy <br />lV� {,!C1(AS �k�P� <br />i <br />v(� <br />(e! J <br />E <br />E <br />,U�! <br />b <br />E <br />R <br />M", <br />:., <br />T <br />C. <br />SEV <br />O <br />4 <br />R <br />d. <br />MAN <br />wq <br />h- a6,,s'.u�b �$ <br />z'� rte' ? <br />' <br />IN <br />� <br />?`.ii: � a �' � ,.�� be .�� v.. TY"� .a.,.�sA"�?e�. ,¢� fr���,T. � $+$.�F��`•;Pk.�.��s.. .��. � �'�.r �:: <br />15. Special Vpndling Instrd Aaiat,o.n, alhnf <br />7 <br />W n�Cf <br />; r /65 <br />JTJ!(� �7 �Z0,9W r <br />o W <br />2 N2 e„te:9S7CA <br />16. GENERATOR'S CE IFICAT ON: I hereby declare that the contents of this consignment are fully and accurately described above by proper shippingname and are classified, <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 />C <br />7 <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 />+ <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 />threat to human health and the environment; OR, if I am a small quantity generator, 1 have made a good faith effort to minimize my waste generation and select the best <br />waste management method that is available to me and that I can afford. <br />Printed/ ed Name <br />Sig atur <br />~\ <br />Month Day Year <br />C.. S> % S <br />® <br />Gt G <br />L/ 3 <br />r t <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />J n <br />Printed/d Name ` <br />t `QV1OYLtA. <br />Signator <br />Month ® Day Year <br />[T[ EJ2 <br />Ll P <br />'> 0 <br />18. Transport r 2 Ackdowledgement of Receipt of Materials <br />jr <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />L E <br />R <br />U <br />19. Discrepancy Indication Space <br />� F <br />j A <br />Z I <br />I <br />20. Facili Owner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19. 1% <br />T <br />Y <br />Printed/Typed,'/Name <br />1 l LR <br />gnatu e / <br />Mon h D Year <br />1 • ;O • <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />DTSC 8022A (9/93) (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 />