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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-991 See Instructions on back Of nage 6. Department of Toxic Substances Contra <br /> Please print or type. Form designed for use on elite(12-pitch; -niter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. venerator's _ No. Manifest Document N,,. 2. Page 1 Information in the shaded areas <br /> Tis not required by Federal low. <br /> WASTE MANIFEST s of <br /> 4 1, <br /> 3. Generator's Name and Mailing Address �- A. State Manifest Document Number <br /> 2337 550 9- <br /> PX".*6ox 802-49 B. State Generator's ID <br /> vi 4. Generator's Phone (! ct:i M.r�;-.1...:](- i 1 Sf1"4]ch(-- Sa-(OJ31ff g"-JAR CA% P2688 <br /> cv 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> p D. Transporter's Phone 460 <br /> O t.:C'..''s�'i.SY''.'.,t�ti,'21"t.}�ii17.�nxsA`i I'lkl.t? ..7Zi, + <br /> o? 7. Transporter 2 Company Nome 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> Q <br /> F. Transporter's Phone <br /> U 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> Ce ",% o 140r&,Ajxnr-da weei H. Facility's Phone <br /> Q 12. Containers 13. Total 14. Unit <br /> 11. <br /> V . US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> No. Type Quantity Wt/Vol I. Waste Number <br /> Z a. if�seline tiS.T.'s' ., <br /> = State <br /> 1.34 <br /> 3 Gx, ! EPA/Other <br /> CD N b. <br /> State <br /> co E <br /> R EPA/Other <br /> v A <br /> o T C. <br /> State <br /> O <br /> R EPA/Other <br /> w d. <br /> F- State <br /> Z <br /> w <br /> V EPA/Other <br /> LU <br /> V) 1. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> 20104t 1'S[5rth"t?m,3eric#ri.RbaS'.g.-{tG1M..< f 1ZES'PO TM 0121.YXNo. 128 0. b. <br /> w Ile I..DR NotificaboTt sti;l#:eTTient.is not required ms c,f-Jit.-amy, 1-.-44xS <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> Q G:tTsc hne mad Water zjyylre W(;U :gig+}'ate ��grc'Y�cti.,� ARC() 492.1? <br /> Z ;1t1Lk}itfw, 6 usst Sm-dME V4 ay <br /> LU , r,s <br /> F c}.Tip)��?9-7,,'756 2�i g naw,Gtx;t:rpanci=:�`tic�w) 57 C,.11C1Krf,�.",� C.A. <br /> Q 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,packed, <br /> V marked,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 /> 2 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 economically <br /> a practicable and that I have selected the practicable method of treatment,storage,or disposal currentl available to me which minimizes the present and future threat to human health <br /> N and the environment;OR,if I am a small quantity generator,I have made a good faith effort� tni ize my waste generation and select the best waste management method that is <br /> 0' available to me and that I can afford. <br /> O <br /> } Printed/Typed Name Signature T Month rDay r, Year J <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materi Is j <br /> acZ5 R <br /> w A Prigted•/Typed Name Signature „> .• Month Day Year <br /> LU <br /> P 1�' rl i.s. t.,✓ <br /> w 0 18. Transporter 2 Acknowled ement of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> w E <br /> Q R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I <br /> L <br /> 20. Foci Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> j Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DISC 8022A(1/99) <br /> EPA 8700--22 Yellow: GENERATOR RETAINS <br />