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state of California—Health a W are Agency Sea Instructions on Back of 0400 6 Department of Health Services <br />Form Approved OMB No. 2( 9 (Expires 1) <br />and Front QlR T �Substances Control Division <br />Please print or type. Form for'ua4 12 ch er), c Sacramento. California <br />FORM RD®US t. Generator's us EPA ro No. Manifekts 2. Paget Intoreaiat shaded areas <br />No <br />AST M IF T of ® Ia net re Federal taw. <br />3. Generator's N @ Mailing Address A. State Meafte <br />Santa i i risk, Lincoln v <br />Diamond aat Vorth St.s Stockton, CA 95206 0 , <br />q. <br />4. Generator's Phone ( ) <br />5. Transporter i Company Name 8. US EPA ID Numberto Thtn <br />n <br />acv <br />w- D. T s <br />7. Transporter 2 Company Name 8. US EPA 10 Number E. Slide Trainspoli ID <br />iI <br />°PQ <br />I I I I I I I F. TransporWe Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number G. State FacAfty's to <br />Fort Irwin Rd. T a t Facility, CA <br />U <br />, T <br />C/O 740 East Carnegie Dr., San Berdino, CA 92408 <br />'a <br />K Fa~e Phone <br />1tion pncludin Proper Shipping 12. Containers 13. Total 14. <br />1. US DOT Description Q pe ipping Name, Hazard Class, and ID Number) Quantity Unit Waste No. <br />No. Type Wt/Vol <br />�a. <br />on H as Solids <br />11 <br />G <br />cq <br />EN <br />CkWoKI <br />} Ar <br />E <br />R <br />b. <br />OF + <br />A <br />T <br />gpAjoihar <br />N <br />o <br />.p <br />R <br />C. <br />d. <br />Z <br />>A1 <br />J., AddNlanal D Materials Listed Above <br />tt. manduig codes far atttea Eisteai we <br />1.. <br />S <br />15. Special Handling Inatrucions and Additional hkformation <br />24 r ct« Nick Hardin <br />4 Hour Pho ± ; 714 1 <br />.j <br />U <br />18. <br />r <br />GENERATOR'S CERTFiCATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br />slid are classified, packed, marked, and labeled, and aridin an respects in condition for transport by <br />proper highway according to applicable international and <br />national government regulations. <br />If i am a large quantity generator, t certify that I have a program In place to reduce the volume and toxicity of waste generated to the degree I have determined <br />to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal <br />' r <br />currently available to me which minimizes the <br />present and future threat to human health and tha environment; OR, If 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 1 can afford. <br />Printed/Typed Name Signator@ f Month Day <br />WfL <br />,Year <br />E <br />ty <br />R <br />17. Transpo er 1 Acknowledgement f Rec9pt of Materials <br />N <br />Printed/T Signature 10 Month Year <br />wed//Name <br />%Day <br />At/ <br />W <br />PA <br />O <br />vJ i <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />Q <br />T <br />Printed/Typed Name <br />Signature Month Day Year <br />E <br />Z <br />19. Discrepancy Indication Space <br />F <br />A <br />T3L C'Gt� j <br />C <br />NAMK 36-490')381 <br />L <br />1 <br />T <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in item 19. <br />y <br />PVIn/Typpd Name J. <br />Signature 0 Month Day Year <br />iN �QVS 0 <br />DHS <br />8022 <br />A Do Not Write Belo This Line <br />EPA <br />8700-22 <br />(Rev. 8-89) Previous editions are obsolete. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />