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'1�weearsAgency sp--oo3g(Expires g-3p- I DeOartmsttt of Health Services ` rarer+designed for use on eAre Heti fypewrffer). I� Toxic Substances Conlral Dtrtalon I Sacramento,California ISM HAZARDOUS merstora US EPA tD No. Man)test Pape 1 I WASTE MANIFEST , Document No. InI.Onrutiort In the shaded areas r ! of is not squired by Federal law. 3. eneralor'a Name(And M�Iling Addres F /,y� A. State Manifest Document Number I '�J, n,r.4,:. ��ft �.: . I i� "_7Gk'/ f-f L P'` L : �i- ];� ,+, 8. State Generators ID 4. Generator's Phone fw I r'�)SE r I 1 ✓ / ' ' 6. Transporter 1 Company Name 8. ie US EPA ID Number '1 C. State Trans stoners ID ;,;F•.. t n j I LU Pt:wr6 I t:um f► .� 0- S 0 6 7 J �i rC Cf D. Transporiere.Phone., 7. Tr ap er 2 omp�yry Name 8. US EPA ID Number ' E. Stale Transporter's_1D`__&;r [' , f �'•7, 1 A — i F. Transporters.P g. Designated Facility Name and Site Address Y 7 .= 10. U5 EPA Ip Number ; G.'Stale F.aculty'g Ip f,>.rlr;`rtes Service ;'.;, 7► a i3 $ 3"1 i.1 ji r. HWY acs Paiterion { if Fadlity'e Phone � � (+ ii () a 71116 114 1711216 0:.X)874-rpt 44 11. US DOT Description(including Proper Shipping Nome,Hazard Clan,and ED Number) 12`containers 13. Total 14, No. Type Quantity Unit -•,•�:._waste No. wtrval G :VtSTE FUZL Lig:+ USTIiLE LIQUID N Nus. WA 1:`93' - I' T EPA/other - E b. k it R li. l S ata r T {. O II EPA/Other I.: State E ` EPA/Mar. d. State- J. late J. Additional Descaplions for Materials Liatsd Above K Handling.p Codes for wastes Listed Above ��a .r�Tk nl I{IuSATE "; r 3, a a p; ., - f f: r �s ''.� w� f' .=1♦e-1- -t ��. -� `j r .. 1 r S � C '� i,-Z ':1A.� d. F -' ?� - t. i - r r .. t �,tx irl •t. '_,- " +i f" 1{; r1; rF a 'f �'� Ir �C'�� r {a�•F+ k .rS•' �."1 r j '- 16. bpeclailiandllnp Instruetlpns and Additlonal Information' "E A'Pt'tWRIAU PROTECTIVE GEM �ESICA,MTE0 FACILITY- FjiLRaEhCY Cl��TACT ;7 (SUC) k-44x44 i c�.t1; ir[k't E:•3Cati, ;rCY CWJAC7 ;.: GENERATOR'S CERTIFICATION: 1 hereby declare that tits contents Of this consignment are fully and accurately descrfbedlabove 6 and ars claoaleed,packed,marked,and labeled,and aro In All res ecte M Y proper terra no name �. national government regulallona. I p �oper.condldan for transport by highway accoNinp to applicable InterneUoaat and E If 1 am a large quantity generator.I cenlfy that I have o to be economicaU program In place to reduce the volume and� xlclly of waste pane.ted to the degree 1 have determined y proctFco hu and That f have selected the practicable method or the storage,Or disposal current available to me which minimizes the present and future threat to human health and the env9rwmranl;OFt,e I om a small quantity generator,I have made a good faith effort to minimize my waote • generation end select the beat weals management metltod that is avollable la me acrd fhal 1 can afford. Printed/Typed Name , Slgnatura 1 I Month Day Year ....�... . .• ' , � , - � - _ • .�.�; �� fry �r l 17. Transporter 1 Acknowledgement of Receipt of materialsr j ' ~ter 1 1r i Printad/Ty d NEe;,� Signature ; , Month Day Yaar 18. Trartsponer 2 Aoknawladgemenl oReceipt of Materials 1 Printed/Ty ams 1 Signature / kle Ile Month Der .year ) e , 16. Discrepancy Indieallon Spaeo ll r 20• Fatality Owner or Operator Canfficallon of receipt of hazardous meteriata covered by this maniteat except as noted in earn Is. Printed/Typed Name i1 Signature t• •r i `.J f' Month Day Year '22 A(1/88) 4 !� '00-22 Do Not Write Below This Line i F38)Previous editions are obsolete. GREEN: HAULER RETAINS