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k <br />i. <br />State of Colifomio—Environmental Protection Agency v� <br />Form Approved OMB No. 2050-0039 (Expires 9-30.96) See Instructions on back ® C ). <br />9 Department of Toxic Substances < <br />Please prim or type. Form designed for use on elite (12�writer. y ..eL <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8tY12A (1/95) White: TSDF Si NDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />EPA 87022A To: P.O. Be, 3000, Sacramento, CA 95812 <br />US EPA ID No. <br />UNIFORM HAZARDOUS <br />Manifest Docur o. 2. Page ` Information in the shaded areas <br />WASTE MANIFEST - 01 ` 1,51113 <br />is not required by Federal law. <br />1.3 0 18 q 16 of <br />` <br />3.rrorarors Name and Mailing Addressin <br />(.Ct, STO� m4fke, -:-i <br />Alf <br />/UCr T`s neb!°N :b,': !; 1,41, Aaav �� <br />h <br />C4 <br />111!1 5,2 v <br />B 'State C wteratot" D <br />to <br />4. Generator's Phone (, /O00 ) <br />xis>; <br />6 <br />5. Transporter 1 Company Name 6. US EPA 10 Number <br />q <br />C ' tr,le T atss !' D <br />1`14 A[5V1Y1XK <br />14/1 <br />"a <br />7. Transporter 2 Company Name 8. S EPA ID Number <br />E'A t Transportet� JDA. <br />U?; <br />z <br />2� <br />'F. •ranspertels� <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />GL°latiadGty' ` D• <br />C1 ick:',On , Inc <br />x,. <br />a �A <br />255 Par? Elvc1. <br />w <br />fid :"�N= Phoria s <br />Rit_tLrl:t:,:,,_A. aYr;n1 C (1 ( <br />E <br />- <br />Z <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total 14. Unit <br />No. <br />T <br />Quantity Wt/vol <br />= <br />a. <br />NDN--RC:A Haza-,doLis Waste. SoJ_iti <br />G <br />E <br />Waste Fi ,tv Storacre Tank . <br />01D 11 <br />Tj r <br />01 44 01 a 16 P <br />0 N <br />Is. <br />p E <br />V R <br />d' <br />T <br />A <br />o T <br />C. <br />Y <br />O <br />LA R <br />s <br />d. <br />u <br />J <br />a <br />7 <br />r <br />i <br />Jill <br />.. r.. x.. r'•.�+' i.... .�, >;'• e . `' .' <br />Fs;,,v :.> <br />_ txvxv"*„;.!_, ::: .wy95,.. ?r^ �. '+K ._�. �. <br />i <br />15. Special Handling Instructions and Additional Information <br />c <br />} ef: I:y away f-rorrki soLirce;s of 1CRut�l"”- nn. Always <br />wear Z'1 ir(liats wl-,el -i wcaki.ncl arom,3 <br />U.G.S,T. ' . 2�1 Hr. Contact N�uT1e.(?Cn? I,i�l.(,°,��_S. <br />rhotl?._�1_` " �_-�_S��l�/ <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, <br />1 <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 />If 1 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 />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, I 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/Typed No J T <br />Signa <br />Month Day Year <br />K90471 <br />T <br />I <br />17. Transporter 1 Ac nowled ement of Recei t of Materigil <br />A <br />Pri <br />/Typed Name <br />Sign <br />Month Day Yeor <br />e. <br />q I <br />0 <br />18. Trans orter 2 Acknowled ement of Receipt of Materials <br />iPrinted/Typed <br />Name <br />Signature <br />Month Day Year <br />I <br />I I I( I <br />19. Discrepancy Indication Space <br />F <br />s. cat <br />A <br />C <br />I <br />L <br />120. <br />Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />T <br />v <br />Print-edd//Ty�°�d Name Signature <br />-�5lli <br />Month Day Year <br />Irr 1v (® ,Ow <br />"'1/0 <br />l 18 1 9 I � <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8tY12A (1/95) White: TSDF Si NDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />EPA 87022A To: P.O. Be, 3000, Sacramento, CA 95812 <br />