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State of Colifornio—Environmental Protection Agency <br />Form Approved OMB No. 2050--0039 (Expires 9-30-96) See Instructions on back Oe 6. Department of Toxic Substances Control <br />Please print or type. Form designed for use on elite (12 -pitch writer. 0 Socromento, California <br />O <br />h <br />co <br />M <br />J <br />a <br />U <br />wt,e <br />(V <br />0 <br />00 <br />co <br />v <br />CV <br />v <br />co0 <br />o <br />w <br />Z <br />LU <br />U <br />a <br />Z <br />0 <br />a <br />Z <br />W <br />F- <br />a <br />U <br />J <br />a <br />N <br />C <br />0 <br />U <br />Z <br />w <br />IX <br />cW <br />LU <br />LL0 <br />L" <br />N <br />a <br />V <br />Z <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. <br />WASTE MANIFEST A p i. Ip I ` I *,1' , <br />Manifest Document No. 2. Page 1 Information in the shaded areas" <br />f is not required by Federal law. <br />31 <br />3. ra_tor's Name qnd Marking Address" Ai $tafBnifpsti3ttcuPttCttt Number <br />.haft{r.?a ys J r <br />. 7 r.; <br />A. Generator's Phone <br />5. Transporter 1 Company Name 6. US EPA ID NumberT #xi3 <br />:7 5 �a <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />ti <br />9. Designated Facility Nage and Site Address 10. US EPA ID Number <br />k..� iii.`. <br />C I. I t 1. ':) <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />a. <br />E <br />N <br />' b. <br />E <br />R <br />A. <br />T <br />C. <br />0 <br />R <br />d <br />0 <br />13. Total 1 14. Unit <br />No. <br />oil ( 'rI E! 1014y1oIi1 I%-,( ` <br />5. Special Handling Instructions and Additional Information <br />iOk`tin,i <tu,All l. <br />i.' ':( . ,_� i�lf ' �:_�ft ��_.� 1,Irtisv-� .�isr�'_ _i•; , l(>" �;.,�.`�, ��� s�'E fc,i�1,_, - <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 />pocked, 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 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 humon 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 Noma ` i <br />Signatth <br />/ � r Month Day Year <br />T 17. Transporter 1 Acknowledgement of Receipt of Materials <br />A <br />A Prir1{fed/Typed Name <br />1.', Signa s ,i --- TMonth Da�1 Year <br />Fi �.' `1 ` i f�`'1_ `+; C\..`w' �,JY- :...ir, �:✓;� C -i,.: " ""fir { C7 '�f G <br />0 18. Transporter 2 Acknowledgement of Receipt of Materials t <br />A Printed/Typed Name Signature Month Day Year <br />E 1 <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by 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 (1/95) Yellow: GENERATOR RETAINS <br />EPA 8700-22 <br />