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State of California'-Health and Welfare Agency^ D gartmanI of Health Services <br /> Form Approved OMB"o.2050-0039(Expires 9.30-88) Toxi nces Control Division r <br /> Pisses nnt`or. e. Form dee ned for use on elite 1 "ch typewriter). .mento,California <br /> UNIFORM HAZARDOUS I N./erstor's US EPA ID No. Manifest2. Page 1 Inform 4 ae y <br /> WASTE MANIFEST O 131 Document No. i Ilba <br /> of ie not Ire y e <br /> 3. Generator's Name and Mailing Address A. State Manifest Documentof ar4.0 <br /> 0V telz Pn,Anse. ��Tit v(cIns, � �R <br /> V-17 It tr p .C'ils9S G <br /> �TDC� T�r �A Z p B. State Genantor's <br /> 4. enerator'$ honfs(Sol) <br /> 6. Transporter I Company Name 8. US EPA ID Number C. State Transportar'a ID S <br /> HILL4i(V -77(14CIt-wdCl D. Transporter'. , <br /> a3 7. Transporter 2 Company Name S. US EPA ID Number E. State Transporter's ID <br /> Q F. Transporter's Phone <br /> L 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility'.ID <br /> N21,1 <br /> M. Facility's Phone <br /> Z rFrr�E�,q <br /> (-/7-%/, c4 fV-T9 ICA Cri o 0i o Yi It I i 105 <br /> 12. Containers 13. Tate l 14. I. <br /> OW 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and 10 Number) Quantity Unit Waste No. <br /> No. I Type Wt/Vo <br /> Z G a.C~ALI�IIE�nllyl} �UiA �J W�S/E Q !Gy State 6/1 <br /> N O O ' EPA/Other <br /> 3 E b. State <br /> c R + <br /> m A <br /> e T EPA/Other <br /> FC. State <br /> ffiQ EPA/Other <br /> W d. State <br /> Z <br /> Z <br /> W <br /> U EPA/Other <br /> W <br /> m J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> O <br /> SDI.c. ConJT.61.'+(f��%�a I.JITid DIE1'E.c.y ° <br /> J <br /> O <br /> 15. Special Handling Instructions and Additional Information <br /> Z �c0 ES I/1F7 / Cit�+stet <br /> rLF 4# -'CFo - — 31 <br /> O <br /> to. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> a International and national government regulations. <br /> r/1 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 1 have <br /> tF determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to <br /> O me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator, I have made a good <br /> > faith effort to minimize my waste generation and select the beet waste management method that is available to me and that I can afford. <br /> WW7 Primed/Typed Name Signature Month Day Year <br /> R 17. Transporter I Acknowledgement of Receipt of Materials <br /> I< A Primed/Typed Name Signature / Month Day Year <br /> O P 7 <br /> W O 19. Treneporta 2 nowledgement of Receipt of Materials <br /> N R Printed/Typed Name Signature Month Day Year <br /> E <br /> Z <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I 20. Facility Owner or Operator Certaication of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> I <br /> DHS 8022 A If/87) INSTRUCTIONS ON THE BACK <br /> EPA 8700-22 YELLOW: GENERATOR RETAINS <br /> (Rev.9-88) Previous editions are obsolete. <br />