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Fes' .� FormApprov"CiMB No.`2060--0039(Expires 9.30-0.1 ToxicSubstancesControl Division <br /> Please print or type. (Form designed/or use on el- ?-pffch fypewrfrer). Sacramento.Cellfarnle <br /> UNIFORM HAZARDOUS Generator' U EPA 10 No. Manifest �� 2. Pape 1 Information M the shaded areas <br /> .— nt o- <br /> c-: ' <br /> WASTE MANIFEST �° f of la not required by Federal law. <br /> 3. Gsoieratof s Name and Mailing Address A. State Manifest <br /> 111"650 3 <br /> . !) fk t ,► '. to,/. `� '" `, f •A S. State Generator's D <br /> 4. Generator's Phone ) <br /> „i $ 6. Transporter 1 Company Name 6. US EPA ID Number C. State Transpor lees ID <br /> r• s P <br /> N <br /> l.,: 7. Transporter 2 Company hams 6. US EPA ID Number E f'f!ltiFT►aaapertara ID ._. ... .,- <br /> I' ,.T►aMportars Picone i +R_ . <br /> 9. Designated Facility Name and She Address /0. US EPA ID Number _ Q State FltSllty'a ID. 1'-e <br /> y`t �1� Fl fseNMy'q.Pnoh! <br /> US <br /> 12. Containers 13. Total 14.tl <br /> I. <br /> 11. US DOT Description(Including Proper Shipping Name.Hazard Class,and ID Number) Quantity Unit wasti N6. <br /> No. I Type Wt/vol <br /> was do"r ebmw to <br /> N State <br /> E b. <br /> a0 R <br /> A <br /> EPA/Other <br /> N O <br /> V R o. t state <br /> EPA/Other <br /> aStat e <br /> d <br /> s' I <br /> W <br /> U EPA/char .. <br /> W ' 1 ALTI <br /> Wltedwo LNtea Abd",p�tIffGf11� , }� r K, Hsndlktn Codes for wastes lasted Above <br /> _ ``. LK j �4• F.+r yir y, i: � --Lx 7 ay�r' - - <br /> �i W <br /> _ Q •J f"F4j a /r 9���k.-.-r` _ �Vi,1`" e r -r d _ <br /> 16. Special Handling Instnic and AdditionalInformation t y ``'' SW Aid '. •„ <br /> ftft'60060 at <br /> taft <br /> i.' QW&RATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and ars classified,pecked,marked,and labeled,and are M all respects In proper condition for transport by highway eaccrdInQ to applicable international and <br /> national government requlatloml. <br /> if I am a large quooft generator,1 earthy that 1 have a program In phos to redncs the volume and toxicity of waste generated to the degree 1 have determined <br /> . to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> f present and future threat to human health and the anvkonmaM;OR.If 1 am a small quantity generator.I have made a good faith effort to miMmiza my waste <br /> generation and select the beat ware management method that Is avalfable to me and that 1 can afford. <br /> Printed/Typed Name Slgna urs J a,'• Month Day Year <br /> W R 17. Transporter 1 Adm <br /> mowledgsent of Receipt of Materials — <br /> ' edi'Tme <br /> d <br /> C k� A PHnt rms Sl9nat Month1. / Day Year <br /> +± : W 18. TrartaporlM 2 Acknowledgement of Receipt of M rials <br /> r. V' RA/onth Day Year <br /> T Prirttad/Typed Name Signature <br /> E <br /> 19. Discrepancy Indication Space <br /> � F ' <br /> s` A <br /> 1, C <br /> • s. f <br /> 4 <br /> 1 20. Facility Owner or Operator Cartincation of receipt of hazardous materials covered by this manifest except as noted In item 19. r <br /> T <br /> Printed/Typed Name Slonature <br /> Month Day Year <br /> Dks 8022 A(1188) Do Not Write Below This line YELLOW: GENERATOR RETAINS <br /> EPA s?00-22 <br /> (Rev.9•69)Previous edltkms are obsolete. <br />