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rareofuelnorNa--Healthand Welfare Agency' . � fl /(�; r �' tl y� ( (" <br /> ,;,are <br /> Approved OMB No.2050-0039(Expires 9.30.88) l T,' - Department of Health Services <br /> Pleasn nnl or s. Form dee neat Iw use an elite I' '•eh To p Substances Control Division p <br /> typewriter)._ Sacramento,California <br /> UNIFORM HAZARDOUS 9rotor's US EPA ID No. Manifest . Page 1 Inform t areas <br /> WASTE MANIFEST O o / s't j 3 °ov"an °f 1 <br /> a no I <br /> 3. Ge ar tw' and Mein GoreM A. Vent anife�t ocum nt umber <br /> w�Of�-T � 2. .s=/t01Cr:S mac.. . �"ent u � <br /> Q ST/c�ET <br /> S:rocu: mov, B. State Generator <br /> a. Generator's Phone(209) g YI Z 8 <br /> Qj 6. Transporter 1 Company Name US EPA ID Number C. Slate Transporter's I <br /> N CNtµlOk- O'A 7' MW40 fi A-V.l! 'r Alble C+3Jfgr / j S' D. Transporter'•Phone. <br /> 9 T. Transporter 2 Company Name e. US EPA ID Number E. State Transporter's ID <br /> g F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. Stell Facility's ID <br /> v 3%ZSI or-) SKYCI A/c 671.J , <br /> H. F cilitY Phone <br /> f3a CA -f0049tt1 5`- 9411 <br /> 12. Contelners 13. Total 14. I. <br /> LLL 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Westa No. <br /> Q No. Type Wt/VO <br /> Z G a' CA LI FoR✓I11 0:0(e( 1474,-) U!/�L/t co-, y State " <br /> N 0101 6, (ID,-r <br /> 6. / r EPA/ghatE b. state <br /> S R <br /> $ A <br /> d T EPA/ghat <br /> N O <br /> R C. state <br /> EPA/Other <br /> d. <br /> Stell <br /> W <br /> U <br /> EPA/Other <br /> W <br /> 2 J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> w $Olt �ilfY�M►/.1/ATE'(� (Jl'T{� �l���L+ ! a. b. <br /> Tit�1U1 MarSlr�N Gc arca .N+t 7?�it o/Cz d. <br /> 15. Special Handling Instructions and Additional Information <br /> ZZ <br /> U le. <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 /> S international and national government regulations. <br /> r7i If I am a large quantity generator. 1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have <br /> determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to <br /> me which minimizes the present and future threat to human health and the environment; OR, If 1 am a small quantity generator. I have made a good <br /> Ufaith effort to minimizeTMy waste generation and select the beat waste management method that is available to me and that I can afford. <br /> yt Prin ITypsd Name - Signelure Month Day Year <br /> W R 17. Transporter I Acknowledgement of Receipt of Materials <br /> A Print /Typed Name ? - Signature _ Month Day Year <br /> N <br /> P 18. Transportep•2 Acknowledgement of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> U E <br /> 2If <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Primed/Typed Name Signature Month Day Yeo <br /> V <br /> 11 <br /> DHS 8022 A(1/87) INSTRUCTIONS ON THE BACK <br /> EPA 9700-22 YELLOW: GENERATOR RETAINS <br /> (Rev.9086) Previous editions are obsolete. <br />