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ate of Ora ns—neann an® neeeaoe nyency *fit insauk tivisu 4iti ®Q4N 41 r dwe u c paremeni of tseenn :jervcas <br />P F: ;.-ivprovsd OMS No. (Expires. -30.91) Toxic Substances <br />and Front of PsBg T Control Division <br />PI"" <br />C -1 -*cit -). 38 --Mo. California <br />print or typo. Form deaignod for use an Sze,- <br />' <br />UNIFORM HAZARD ator's US EPA D I+b. Mantte ; ' .Paget Information h to shaded ants <br />WASTE MANIFEST 41471 A of ' Is not required by Federal is.. <br />S ator's Mal A j A. State Mantbsrt DOC~ Numbst <br />90792176 <br />ro. 0 q�ZOO a. State .®� <br />4. a C <br />b. Transporter 1 Company Name 8. US EPA ID Number C. State Transporter's t0 <br />/At Q Q O b 6 Z D. Transporters Photw rip 2 tjr <br />d <br />T. Transporter 2 Company Name 8. US EPA to Number E. State Transporters ID <br />F. Transportee, Phoma <br />9. Designated Facility Name and Site Address 10. US EPA to Number O. S e Faculty's ID <br />Ec ®w.•t <br />J <br />J <br />v <br />OPhone <br />tiao cq D 0141312-1 Z® g jse <br />12. Containers <br />18. Total <br />14. -L <br />11. US DOT Description pncluding Proper Shipping Name. Hazard gess. and ID Number! <br />No. Type <br />Quantity <br />will Waste No. <br />v <br />a. ®; /y R. t-x!p <br />2Z3 <br />® <br />E <br />®d r <br />EPA/ <br />N <br />E <br />b. <br />State <br />R <br />A <br />;. <br />T <br />EPA/01hat <br />O <br />n'set R <br />c.State <br />f S <br />d. <br />Stats <br />EPA/ <br />40 <br />J. Descriptions for Matte listed AboveK4 <br />Cod" for Ws <br />b Above <br />"L isRsd <br />b <br />Wf 41407ba.Otc, <br />j <br />W. <br />C. <br />d <br />� <br />J <br />15. Special Handling Instructions and Additional Information <br />_71 t 1>a _—it 0 <br />U <br />J <br />GENERATOR'S CERTIFICATKK I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping 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 government regulations. <br />® <br />*$ <br />If 1 am a "a quantity generator. I certify that i have a program in place to reduce the volume and toxicity of waste generated to the dowse I have determined <br />to be economically practicable and that I have selected to practicable method of treatment. storage. or disposal currently available to aur which minladzes the <br />present and future threat to human health and the emrk • OR, N I am a small quantity generator. I have made a good faith effort to minimize my waste <br />generation and select the best waste management method that is available to me and that I can afford. <br />Printed/Typed Name <br />Signature Month Day ,Year <br />W <br />^� <br />I R <br />17. Transporter 1 Acknowledgeirfent of Receipt of Materials <br />A <br />PriMed/Typed Na e Month Day Year <br />N <br />c <br />WO <br />/8.'Transporter 2 Acknowledgement of Receipt of Materials <br />Go R <br />T <br />Printed/Typed Name <br />Signature Month Day Year <br />fJ E <br />2 <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />L <br />T20. <br />Facility Owner or Operator Certification of receipt of hazardous materials covered by thlapariffest except as n,%pd In lt 19. <br />y <br />Prkr/Tybed Name <br />SignalMonth Day ' Y r <br />DHS 8022 A Do Not Write Below This Line ' <br />EPA 8700-22 <br />(Rev. 8.89) Previous editions are obsolete. White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />To: P.O. Box 3000, Socromento, CA 95812 <br />