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State of Ca4fornio—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9.30-96) See Instructions on back ge 6. Department of Toxic Substances Control <br />Please print or type. Form designed for use on elite (12pitc . writer. Sacramento, California <br />O <br />V) <br />W) <br />n <br />CV <br />to <br />00 <br />9 <br />Q <br />U <br />00 Z <br />ry <br />C:) Q <br />U <br />Z <br />h <br />3 <br />CIS <br />C <br />00 <br />00 <br />v <br />N <br />v <br />CO <br />aC <br />CX <br />LL <br />t— <br />Z <br />LL <br />U <br />LL <br />V'. <br />C <br />V <br />LL <br />a <br />LL <br />H <br />Q <br />L <br />ii <br />V <br />C <br />L <br />2 <br />LL <br />LL <br />U <br />U <br />C <br />U <br />u <br />L <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/95) Yellow: GENERATOR RETAINS <br />EPA 8700-22 <br />1. Generator's US EPA ID No. <br />Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />�y <br />r '� ° - <br />!� <br />' <br />snot required by Federal law. <br />WASTE MANIFEST <br />( �; ( <br />s <br />of <br />IS <br />3 Gert rgtor s N • a�,,�{ 1109p <br />lop ip,st0C,cument Numbpr.. <br />.. <br />-7-S h 7`ar1f; e' <br />g <br />r <br />s <br />4. Generator's Phone <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />6A, 1� <br />J" <br />� N <br />7. Transporter 2 Company Name 8. US EPA ID NumberD <br />9. Desi noted Facility Name and Site Address 10, US EPA ID Number <br />:,� <br />�t <br />h <br />it <br />�`.y� .P�'fi.� b. <br />tt?..�.�dRt•����.L <br />12. Containers <br />.eM1i.. t.i� .f.*,.=... <br />13. Total 14. Unit <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />No. <br />Quantity p�) <br />Wt/Vol 1 3L,aIvmisg,= <br />Type. <br />o.(.�'i• t��'!., i-4<ti�.•[��.i:l�:'iu 6ti.�t�::'ts.. .-_,:1i3 <br />�� � ;� <br />EfsAO ret <br />R <br />T <br />C. <br />O <br />� <br />N <br />gM1 { <br />R <br />d. <br />Stt7fe p� e y <br />eft. <br />a <br />t. <br />15. Special Handling Instructions and Additional Information <br />t r,,At 11 -'e E; .f Ictri i't t i , ;' J 'cl y :S. <br />rk-ctr h1 11,1'.Ttc'3t S 41,1:�rl )r -i I v,j 'Ll 1, <br />i r";,:";.'T'. ':: :1 'r§r '�'cxtt�t`+: 15�=ttla--L,G/ 1�=s �?I;;fl� �_ ��J`�✓ �1�.-s <br />.,f�`.��r" <br />..� <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 />packed, marked, and labeled, and are in all respects in proper condition for transport by highway <br />according to applicable international and national government regulations. <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 />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 manage ent method that is available to me dnd that I can afford. <br />Printed/Typed Name I <br />SignatureMoQih <br />Dox <br />T <br />17. Trona orter'1 AcknowledgensW of Receipt of Materials i <br />R <br />A <br />Printedjy Narpe -1' <br />Sign <br />MrN�, �D `' C �c}► <br />0 <br />18. Transporter 2 Acknowledgement of ecei t of Materials <br />R <br />T <br />Printed/Typed Nome <br />Signature <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />20. FacilityOwner or Operator Certification of receipt of hazardous materials <br />covered b this <br />manifest except as noted in Item 19. <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/95) Yellow: GENERATOR RETAINS <br />EPA 8700-22 <br />