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1&--Hea f1h and Welfare <br /> pet <br /> W ��movedO B N.,2050--0039(ExQeep 7r i Department of Health Servic <br /> jToxic Subetencea Control Divis <br /> �print or type. (Form designed for ase on efite(12-pifch typewriter). In0ructi-hp'0r} 4� �(' Sacramento,Califor <br /> UNLFORM HAZARDOUS 1. Generafor_s US EPA ID No. Manifest, 2. Pape 1 <br /> �IASTE MANIFEST`'- `" `` ' t .. , Document No. Information in the shaded arses <br /> -0. of is not required by Federal law. <br /> 3. Geharalor's Name and Mailing Address' A, State Manifest Document Number <br /> :�ht q <br /> ,3 ;1?J i ti I' t c <br /> , Yi <br /> State enereior'e D2 <br /> 4. Geiierafor's Phone t' } <br /> C."- <br /> ,L 5. Transporter 1 Company Name t3. US EPA ID Number C. State Transporter's ID ` <br /> i D. Transportor's Phone <br /> p 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> 0 <br /> Q F. Transporter's Phone <br /> Q} <br /> 9. Dep{p��tyd�aciliiy N ,a.�d site A res 10 US EPA ID Number G. estate Facility's ID <br /> P.. J r�U 1dF CH A Lc� �'D�2,gZ`1r� <br /> H. Facility's Phone PALOL o � "3� 3CO T S �D S 7Q � 6 3s <br /> qq- z <br /> 12, Containers 13. Total 14. !, <br /> 0 #1. US DOT Description(Including Proper Shi <br /> P Aping Name,Hazard Cess,and ID Number) Quantity Unit Waste No. <br /> `W dNa. Type �Wt/vof <br /> z a FLAt(0X L14 M.A(5,L� �L(00i(�, A.1A' !2(D3 FOo3 <br /> 1J T G <br /> N L EPArO;her <br /> ry R b. !✓�l r-2D I2D r�, '7J f1 fiL =y,'�'7 C� Stale <br /> JI ,%,'; <br /> O n r`r /✓; ! r.-,r 7 EPA i OYhor <br /> c R ,. <br /> p <br /> State <br /> O f <br /> m� <br /> 1 EPA/Other <br /> I <br /> d State <br /> uy 1 <br /> 0 <br /> I EPA;C tia <br /> Ll <br /> i <br /> `c J. Additionot DescriPaor:s for Malerais Listed Above <br /> K. Handling Codes for Wastes Listed Abeve <br /> b. <br /> CL 1-WG OV/(�1, 4 <br /> w� LAS IC�0/ e5,4. j("tiAf N.' Yk4`Y� 1- f1yL 7C1iV <br /> zi <br /> of <br /> r 1 15. Special Hanaiinu instructions and Aaditional Information <br /> `zl <br /> W r'1!'i6At E•}= >~5.7' JAPJ-0267 <br /> M `'{_tiV1S, CO�,G��� ���• f�.'��`�Cia �74� C�E:,'�t-tk�� <br /> J <br /> J <br /> C 16. <br /> V <br /> GENERATOR'S CERTIFICATION: f hereby declare that the contents of this consignment are fully and accurately described above by proper shippolg name <br /> and are classified,packed, marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> national governmeri regulations. <br /> Cr 111 am a large quantity generator,T certify that I have a program in place to reduce the volume and toxicJy o,waste generated to the degree I have determined <br /> 01 to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently svailabEe to me which minimizes the <br /> } present and future threat to human health and the environrrment•OR,4 1 am a small Quantity generator,I have made a good faith effort to minimize my waste <br /> Z generation and select the best waste management method that is available to me and that I can afford. <br /> Lu Printed/Typed Na,re <br /> (7 Signature Month Day Year <br /> Lu <br /> R 17. T sporter t Acknowledgement of Peceip! 01 Materials _ -_ - <br /> C A - <br /> N f } S'gn Monrh Da_ Year <br /> Lu U 1B, ransporter 2 Acknowledgement of peceipt o1 Materiels <br /> Q Printed/Types Name <br /> UE Signature Month Day Year <br /> i <br /> z <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner ar Operator CerliRcelion o1 receipt of hazardous matene{s covered by this manifest except as noted in Item 19. <br /> T <br /> Y PrfnledlTyped Name Signature Month Day Year <br /> DHS 13022A(I/a8) Do Not Write Below This Line <br /> FPA 8700--22 YELLOW: GENERATOR RETAINS <br /> (Rev.9-se)Previous ed4ions are obsolete. <br />