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State of California --Environmental Prollection Agency <br />Form Approved OMB No. 2050-0039 (Expi?es 9.3096) <br />Please print or type. Form designed for use on elite (12yoitc ewriter. <br />0 <br />Lo <br />CV <br />to <br />ao <br />0 <br />09 <br />Q <br />U <br />N <br />0 <br />00 <br />OD <br />v <br />n <br />0 <br />0 <br />00 <br />Uj <br />w <br />F - <br />Z <br />W <br />U <br />Q <br />Z <br />C <br />h <br />Q <br />Z <br />LL <br />Q <br />L <br />a <br />C <br />} <br />L <br />Z <br />LL <br />C <br />ck <br />LL <br />I <br />LL <br />LL <br />C <br />LL <br />V <br />Q <br />L <br />Z <br />See Instructions on backge 6. Department of Toxic Substances Control <br />Sacramento, California <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. Manifest Document No. <br />2. Page 1 Information in the shaded oreds' <br />UNIFORM HAZARDOUS <br />I } <br />% <br />snot required by Federal law. <br />WASTE MANIFEST <br />�, <br />JJJ <br />of <br />Saenprator's Nalpv. yand, 1�9)ip�.Ad�cess �, f <br />Ml- <br />�� N <br />4. Generator's Phone <br />5. Transporter 1 Company Nome 6. US EPA ID Number <br />00, <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />- <br />( <br />v paw' <br />9. De ' j Hated acili NcTan de Address 10. US EPA ID Number <br />t <br />:,l .. <br />a C� <br />1 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total 14. Unit <br />IN <br />e <br />Wt/ <br />Quantity Wt Vol <br />Vol b <br />1 iAt <br />A <br />G <br />=J� � .: � �-f`� �� �t: ;t, >r ,3i.1t-: 'T'•=taa1<_ , <br />i / <br />'r � <br />� � �� <br />Efl ��� � � � <br />N <br />b. <br />a <br />5ta <br />E <br />R <br />EPA�t?�er <br />A <br />T <br />C. <br />Strom � dict ,3 <br />a <br />R' <br />x> <br />d. <br />;vu, <br />iA 4 <br />s <br />hh 39 <br />15. Special Handling Instructions and Additional Information <br />I!, «-n ':Y)i. t o.-";0 ,A 1(:jTIt_ ic)n. <br />f11:{ ,=;I�r:',iUl� <br />11 �a :4 Ott Alt, <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 and that I can afford. <br />Printed/Typed I�gme9 / <br />Signotgr¢fi / <br />i <br />Month.- pay , Ypar. <br />rp <br />T <br />17. Transporter 1 Acknowledget of Receipt of Materials t <br />A <br />Printed od <br />Signatu7�� / <br />/ �' / <br />j(,`Mn#r Day -r- �Ye <br />P <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of M rials L <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />F <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials <br />covered by this 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 />