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Sate of CalllorNe-Eovbaanen!nl Frnecna Agency / <br /> Form 4ppra+erl OMB No. 2050-0J3c l,.pie,9.3099'I '•`� See instructions on back OI `e B. Dsp_rtmeat of Toxic Sab0a,aes Contrd <br /> Please"'n,or!ype. form designed(cr cse o^elite(12pIKhf yew:iter. Sacramento,California <br /> 1. Generator's US EPA ID No.. Manifest Document No. 2. Page I Infom <br /> ration in the shaded areas <br /> UNIFORM HAZARDOUS I - _ I -` I .. I t:a at required 6,Federal taw. <br /> WASTE MANIFEST of <br /> 3. Generators Name and Phailbag Address - A. Slate Manifest Dacument Number _ <br /> B. Slate Generotar's ID - <br /> a7, 4. Generator's Phone <br /> n <br /> H 5. imnspaner 1 Company Name 6. US EPA ID Number C. State Transporter's ID{Reserved.l ' <br /> h <br /> m _ <br /> D. Transparter's Phone <br /> O <br /> C? 7. Transporter 2 Company Name S. US EPA ID Number E.State Tronsporter's ID IReserved.l <br /> F. Tronspartei s Phone <br /> Q <br /> V P Desig ted# �' <br /> aa)i .Name and Site Address 10. US EPA ID Number G. State Tocility's ID - <br /> .-. a .-. ._ <br /> 'IZH. Facili sPhone <br /> t S <br /> ^ •. - v. ,. ::g t r -:`a 66 ,,& x^ a`q\ as 'p V. ... '' <br /> O <br /> 11. US DOT Description - tvdin Pro Shipping Name,Hazard Class,and ID Number) f 2. Container 13. Total 14. Unit <br /> l./ l' 9 Per PPi^9Epq- <br /> Ouonlily Wt/vol Waste N ber <br /> Z a_ PIZStaleEPA/Other'; a ansa/-. oNF{C�°� roNsateE :i'a5{r.tom,-y". �r 4�'Sc1„ pR t t�R�°4cT� t�i J �'`�^�, �' EP�ah�e`r` <br /> e A <br /> o T state <br /> C) O - EPA/Other <br /> R _1 <br /> w d FEP�A <br /> te <br /> Z <br /> V /Otfi<r <br /> s� J. Addnlo I De cr ti "scar Matec�als:Listed A6ave K Handling Codee7or Wastes fisted Above <br /> Cs- <br /> w <br /> li_t Spinformation <br /> Q 1 .,. dt: ..Jd= -itij`N.t_.i! i4A{?_ .r _ .5747 <br /> Zof <br /> i`'d i 1� i ?IE. i'h.±I-,.�.;•r 2. ys`YZ �TT }...L:s' <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this conig ent are fully and accurately described above hypo,.,shipping name and are ckssi6d,packed, <br /> Umarked,and labeled,and are in all respects in proper condition For transport by highway according to applicable international and national government regulations. <br /> —` if am is large quantiy generator,I«rtify that have a program in place to redece the volume and toxicity of waste generated to the degree I have determined to be economically <br /> Hpracticable and that I have elected the practicable method o treatment,storage,or disposal currently owiloble to me which minimizes the present and future threat to human health <br /> and the environment;OR,if I ora o small quantity generator,I hmme mode a good faith effortrt.13.,minimize my waste generation and select the best waste management method shot is <br /> O mailable to me and that I ca^afford. ( + \ - <br /> y Printed/Typeod Na Signature ! ! Month. Day Year <br /> t 4 <br /> w B n 17. Trarn r 1 Acne owled ement of Receipt of Materials <br /> �j Print ed/T ed N me - Si 're B Month Do Year ' <br /> w RS PB?q aj J-)= �A� tern 1 �T 5 i cr <br /> w 018. Transporter 2 Acknowledgement of Receipt of Materials <br /> O T Printed/Typed Nome Signature Month Do Year <br /> w p <br /> Q R <br /> U 19. Discrepanry Indication Space <br /> Z F <br /> — A <br /> C <br /> I <br /> L <br /> 1 20. Fccilitir Owner or Cheirratror Certification of receipt of hazardous materials tmered by this manifest except as noted in Dem 19. <br /> T Printed/Typed Nome Signature Month Day Year <br /> T <br /> DO NOT WRITE BELOW THIS LINE. <br /> Blue: GENERATOR SENDS THIS COPT TO DTSC WITHIN 30 DAYS. <br /> DTSC 8022A 11/991 To: P.O. Box 400, Sacramento, CA 958120400 <br /> EPA 8700-22 <br />