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State of Colifornio—Environmental Protection AgQency <br />Form Approved OMB No. 2050-0039 (Expires .30.96) See Instructions on backge 6. Deportment of Toxic Substances Control <br />Please print or type. Form designed for use on elite (12-piloewriter. 0 Sacramento, California <br />0 <br />h <br />W') <br />CV <br />W) <br />CA <br />6 <br />M <br />C\IU <br />00Z <br />M O <br />Q <br />CF) U <br />wd ) T <br />3 <br />CV <br />0 <br />00 <br />00 <br />4 <br />C1`1 <br />v <br />00 0 <br />0 <br />rr <br />LU <br />Z <br />W <br />U <br />W <br />to <br />O <br />CLN <br />W <br />M <br />Q <br />Z <br />0 <br />Q <br />Z <br />W <br />H <br />J <br />Q <br />U <br />J <br />CL <br />C/Y <br />tr <br />O <br />} <br />U <br />Z <br />w <br />W <br />w <br />LA. <br />0 <br />LU <br />N <br />Q <br />U <br />G <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 Information in the shaded areas <br />UNIFORM HAZARDOUS <br />" <br />^ <br />is required by Federal law, <br />WASTE MANIFEST <br />4 ;_` rt <br />t <br />3. 9gnerator's Nana and Mailing Address <br />_ � �ti � /rt'- l � �i � � �G. a 1J <br />- ✓ '� ". � _' < <br />� b '�g.�4'C-`"�h �`,� ✓.2a 'i� �s <br />,K ! _ ., � <br />y € <br />4. Generators Phone <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />( r ;i L. <br />o <br />1 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />g'40 „ <br />T, <br />9. De ' noted ffacility Ncqne and Siilte Address 10. US EPA ID Number <br />a <br />t <br />T 1.1 <br />� ..^.. <_ '' ': t 1 `: 1 <br />F t_ '� <br />r <br />• ,t, _i s;.:',t.tL <br />11'tY1 <br />�������'�'a�31� �N <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />14. Unit <br />No. <br />Type <br />Quantity <br />Wt/Vol <br />F„ este Numt?es <br />a. 1 1 1– F'i��` r'{. -i , tl \ Sf �,_t:' C�)2i�, tf� ..x 1. ] •,.1 <br />_r. <br />G <br />• <br />N <br />b <br />4 <br />� <br />0 <br />C <br />" <br />G <br />d. <br />EPii%Cithei <br />1A <br />`iPStfPe <br />A <br />e <br />�..., <br />.. �,� <br />,1�ro`. . e <br />i` _.e*,=„ � C��.",�`. 7a'"��, , <br />.:..,, < ..v .,, .. " "fit` . =.•fit <br />15. Special Handling Instructions and Additional Information <br />i" I' _)1t1 ;3.x_ 1. E:"t _;f i"TI't-it i:)n i4lwav <br />,fea,( It_ai(:hcif s41(,'1'l k)11%1,tcl <br />t .: .:. .. ..;�% )'.). ..;,�dit.d.•',"t: I4�0:10-• <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 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 hove 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 Nam i <br />Signature <br />/ <br />Month Day Year <br />T <br />17. Transporter 1 Acknowled ementiof Receipt of Materials " <br />A <br />Printed/Typed Name $ ' ✓ <br />Sig aj4re } <br />Month, Day Year,, <br />S <br />0 <br />18. Transport r 2 Acknowledgief6int of Receipt of Materials <br />It T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />!Y <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />E <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials 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 />