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£ .te at caFn«ai.—Hsatch and Welfare A -° see Instructions on Back of Page 6 Department of Health Services <br />!� F OMB No. (Expires 9.30 and Front of Pan 7 Toxic Substances Control Division <br />Picas• <br />Sacramento. Ggforela <br />print or type. form designed Dor use an ch typowrited. Allim <br />UNIFORM HAZARDOUS eneratar s US EPA q No. Manifecement t�11111 Page 1 Id t in the shaded areas <br />Art,WASTE MANIFEST •. -- of la vier ed by F-1-1 aw. <br />8. Genorat es i e t a Mair A. State Manifesty <br />7 2176 <br />a. j�®` <br />B. State Generra,oe. 111) <br />.. e _ 'f r_ C: <br />S. Transporter 1 Company Name 8. US EPA to Number C. State Transporter's ID <br />wfN <br />C, ® ®® 6 6 Z D. Transpote's Phone I® 2.W7-4 <br />3 <br />sport Company Name 8. US EPA to Number E. Stat Transporlees ID <br />7. Transporter 2 <br />F. T er's <br />e. <br />9. Designated Facility, Name and Site Address 10. US EPA to Number Q e FaCilltys ID <br />t <br />J <br />t9 ifoi <br />V41s <br />K F s Phone <br />®c 9ICA 00 3 7 ® 4ts' 366 - � II <br />12. Containers <br />19. Total <br />14. <br />-1 <br />11. US DOT Description gnciuding Proper Shipping Name. Hazard Class. and to Number) <br />No. Type <br />Ouantity <br />Unit <br />wttvol <br />Waste No. <br />a-tU O,G• e4gp ►g0 N R' !2?D <br />stat» 223 <br />E <br />® d <br />fPA/ <br />N <br />I <br />State <br />R <br />b. <br />N <br />A <br />T <br />EPA/Odwr <br />.t <br />O <br />N <br />R <br />C. <br />EPAioaar <br />s <br />A1-vjc �1 v�C:O `k- <br />d. <br />State <br />EPA/ <br />U <br />W <br />J for Materials listed Above <br />K Hantift Codes far Wastaa <br />I.Wad Move <br />b.J <br />Z <br />... - <br />Z <br />15. Special Handling Instructions and Additional information <br />`,t, 4Rd,;&P ® _71�! 3 �� �� 1 r <br />J <br />,�S117 <br />J <br />V <br />/8. <br />J <br />GENERATOR'S CERTFICATION: 1 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 arnd <br />to <br />national government regulations. <br />cc <br />F am a targe quantity generate,) certify that I have a program la place 90 reduce the volume and toxicity of west generated to the degree 0 have determined <br />® <br />j practicable and that F have selected the practicable method of treatment• storage, or disposal currently available to ma which minimizes the <br />to be economically <br />to <br />A <br />present and future threat to human health and the environment; OR. It 1 am a small quantity generator. 1 have made a good faith effort to minimize my waste <br />V <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 />ov <br />W <br />T <br />R <br />17. Transporter 1 Acknowledg en of Receipt of Materials <br />ZA <br />Printed/Typed Na`� <br />re Month Day Year <br />O <br />a <br />S15 <br />!QG <br />vk�W <br />` <br />MrL <br />P <br />O <br />/8. Transporter 2 Acknowledgement of Receipt of Materials <br />UT <br />Printed/Typed <br />Name <br />Signature Month Day Year <br />E <br />Z <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />rX <br />I <br />L <br />I <br />T <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this ari feet except as in lt 19. <br />Y <br />Prin d/T ed Name <br />Sign Month Day' Y r <br />L <br />6,6 v <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 DONS WITHIN 30 DAYS <br />To: P.O. Box 3000, Sacramento, CA 95812 <br />