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State of Cali fornio—Environmental Protection Agency <br /> Form Approved OMB No 2050-0039(Expires 9 30 99[ See Instructions on back of page 6 Department of Toxic Substances Control <br /> t Please print or type Form designed for use an etre(12 pitch)typewriter Sacramento California <br /> ' 1 dJ jJ —7 of Generators US EPA ID No Manifest Document No 2 age 1 Information in the shaded areas <br /> WASTE MANIFEST 2 � 7 � +3 j( <br /> Di <br /> HAZARDOUS � is not required by Federal low <br /> �{ <br /> I* <br /> 3 Generator s Name and Mailing Address �NW PL () A State Manifest Document Number A 2 9 7 w 6 1 <br /> ;��jjS� \ LUr�y I ��C t,3 <br /> B State Generators!D <br /> 4 Generators Phone[ I � .1�tL1�J �.•+ Cf. V� <br /> t t\ <br /> CV 5 Transporter I Company Name 6 US EPA ID Number C State Transporter s ID[Reserved I <br /> in <br /> o EP ICAM VALLEY WASTE 01 L 1 P 1 13 ? J? 1 1. ter D Transporter s Pho'800—167-40-. <br /> 0 <br /> C? 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved j <br /> Q F Transporter s Phone <br /> V i g p9e'"d m S dd 10 US EPA ID Number G rot aIV 9 0 <br /> 0300 GLALIES ROAD <br /> O toctr�Kt xssfr ati�als r- w r ? 19t� `" de " rEY�d � Qi e'�3f 4 <br /> s5l'r aJ—eq 1, e s 7 1! N S ! U <br /> J l 1 US DOT Descnphon(including Proper Shipping Name b/ozard Class and ID Number) 12 Containers 13 Total 14 Unit <br /> V No Type Quantity Wt/Val I Waste Number <br /> X a state <br /> NON RCRAe HAZAR i<0II�s WASTE l IQUID 221 <br /> 3 G (OILYINAT'ER p � � T � t✓� C �)� EPA/Other <br /> CN b J State <br /> aOOo E <br /> R EPA/Other <br /> Iq A c State <br /> ' o T <br /> � O <br /> R EPA/Other <br /> LU d State <br /> Z <br /> LU <br /> V EPA Ot er <br /> LU <br /> ul J Additional E+Tl)tJLXcWA'1Ais Listed Above K Handlmgl5*es for Wastes Listed Above <br /> ' a b <br /> e d <br /> 1:Z <br /> 15 Special Handling Instructions and Additional Information <br /> Z MERG ENCY DHOW E 209-136-1-R857 <br /> ' w <br /> t— <br /> 16 GENERATOR 5 CERTIFICATION I hereby declare that the contents of$his consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Vmarked and labeled and are in all respects in proper condition for transport by highway according to applicable international and national government regulations <br /> J <br /> If I am a large quantity generator I certify that I hove a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> a practicable and that 1 have refected the rachcable method of treatment storage or disposal currently available to me which minimizes the present and future threat to Kumon health <br /> 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 waste management method that is <br /> O <br /> available to me and that I can afford <br /> Printed/T pi[ed Naurme Signa Month Day Year <br /> Z rl/✓ .s'v G-UM.1 '� iJYr1+.,. } i f' - <br /> w T 17 Transporter 1 Acknowled ement of Receipt of Materials <br /> 11 Pri fed/Typed Name Signal re Month Da ji� Year <br /> 11 <br /> LU Pi ` <br /> w 0 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> O T Printed/Typed Nome Signature 1� Month Day Year <br /> w E t <br /> N R <br /> ' V 19 Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I <br /> L <br /> I 20 FaaliOwner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19 <br /> T Pnnted/Typed Name Signature Month Day Year <br /> Y <br /> ' DO NOT WRITE BELOW THIS LINE <br /> DTSC 8022A(1/99) Yellow GENERATOR RETAINS <br /> ' EPA 8700-22 <br />