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- 'Califrnia-4d.mamenblProted:a:Agencyiv bsmnces Contra <br /> : <br /> Fo:mP,,rc,d O.mB Nc.205'J-0^'_9!`:ores??099! \,� SEB instructions 81'PUCYIODS Ott BOCK O �, p O. Depoomeof Toxic Su <br /> Please Prim or type. For,,designed for ase on elite 112p;tch, ,w1;1a, .\/ Socramemo,California <br /> 1!Gan.rotor's US EPA ID No. Manifest Document No. I 2. Page 1 Inks'en.ti,so in the shaded areas <br /> UNIFORM HAZARDOUS ria reg -d by Federal I <br /> WASTE MANIFEST I I l l j l -� I °f <br /> 3..Gen rut s Name and Ma ling Address - A. Slate Manifest Document Number. ~ <br /> e. Store Generoror's ID —� <br /> 0 <br /> ha. Generator's Phone l 1 <br /> C. State Transporter's ID Reserved <br /> N <br /> S. Transporter 1 Company Name - 6. US EPA ID Number Por er's (Reserved.) <br /> C? - D. Transponer'x Phone _ -.... <br /> 0 <br /> C? 7. Transporter 2 Company Name 8. US EPA ID Number <br /> E.3rota Transporia7i ID[Reserved.) <br /> F. Tmnsportei s Phone - <br /> e V 8 .Designated Fa 1 yrName d$to Aadr s 10. US EPA ID Number G. State Facility's ID <br /> Z } G s'.3 . ( s H. facility's Phonr. <br /> .i' 12. Containers 13. Total 14. Unit <br /> Q <br /> 2 V 11. US DOT Description(including Proper Shipping Nome,Hazard Class,and 10 Numbed No. T pa Quantity Wt/Vol I. Wove W.1ber <br /> State. <br /> � ,/[ y-t� e EPA/Other ,- <br /> 3 <br /> E <br /> Sort.' <br /> o N 6. <br /> E EPA/Other: <br /> v R <br /> vA state <br /> C. <br /> o T <br /> m O EPA/016.1 <br /> R <br /> Stole. <br /> w d. <br /> Z _ EPA/Other ' - - - <br /> w <br /> V <br /> s+s K Handling Codes:fol wmtes Listed All., <br /> J:Additional D crptioni For Materials Cared Above ' <br /> O f, r„ `Yg:j C b. <br /> 0- <br /> or) <br /> a <br /> Z O 3 5 eoYH ndlefpg7t 7mMi°. dInformation <br /> . <br /> Q •:,. Iii. !. i.. .t:{-.f� t j!`rtfj �:�� � l r _..�i- q <br /> Z -. o t"',J•.. '-A- <br /> 16, <br /> M1 <br /> 16. GENERATOR'S CERTIFICATION: I bleally declare that the conlenb of this consignment are fully and accurately descdbed above 6y proper shipping name and are classified,pocked. <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 If I am a large quantity generator,I certify that have a Pro <br /> grum in place ro reduce the volume and toxicity of walla generated to the degree I have determined ro 6e economically <br /> d practicable and that I have s.I.xsd the pradicabla method of treatment,slpmge,or disposal currently available ro me which minimizes the present and future threat b human health <br /> and the environment;OR,H I am a small quantity generatoq I have made o good faith effort to miniretzp my waste generation and select the best wave management method that is <br /> d' ovaila6la to me and that I con afford. <br /> OSi oNn {� Mang Day Year <br /> } Primed/Typed Name 8n I 4 <br /> w T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> 0. y <br /> 0. Printed/Typed Name n �gndtarla n j° `+ i D°� TaO <br /> 18. Tram iter 2 Acknowled ement at Receipt of Materials <br /> 0. Printed/Typed Name Signature Month Day Year <br /> O <br /> T <br /> W [ <br /> Q R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I <br /> l <br /> 20. Facili Owner or O .tarot Cartificafian of receipt of hazardous materials covered this moniimt este t as noted in Ikm 19. Month Day Year <br /> T Printed/Typed Name Signature <br /> y I I_ I I 1 <br /> DO NOT WRITE BELOW THIS LINE. <br /> Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC 8022A(1/99) To: P.O. Bax 400, Sacramento, CA 95812 0;400 <br /> EPA 87DO-22 <br />