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State of California—Health and Welfare Agency See Instructions on Back of Page 6 Department of Health Services <br />Forth roved OMB No. 20 (Expires 9-30.91) ��1 e3 and Front Of P8 e 7 Toxic Substances Control Division <br />Sacramento, California <br />Piesm <br />pnnfWrtom. Form designed for use on slit pitch typewriter). <br />UNIF M HtAZAR®®US Gerreretor'a US EPA ID No. Manifest 2. Paget <br />Documen <br />Information in 4he shaded areas <br />£o.� <br />WASTE MANIFEST C of <br />fa not required by Federal law. <br />3. Generator's Name and Mailing Address <br />A. State Manifest Document Number <br />n' T e r�` 1 as r t 4 '. ^`± , ,i, ("!I()^. <br />SO 7> '7 <br />S. StateGenerators� <br />D$�9e� r, 5, Ar*�i", f';, ,5�°'°t nn CA �;'_`_ <br />« <br />4. Generator's Phone ( ) <br />p q <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's Kt -� <br />to <br />f" t '": , : <br />D. Trsneporter'e Phone ! , <br />to7. <br />Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID <br />F. T s Picone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Faclifty's M <br />F - r* Irwin Rd. Trpa r`- a:*f1!''. , Cars", -,w, Cf. <br />U <br />�! 740 Etvv rrii�gio Dr. <br />M. Fa~sPhone <br />O <br />12. Containers <br />13. Total <br />14. L ; <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity <br />Unit Waste No. <br />f <br />No. Type <br />Wt/Vol <br />-, z <br />a. sy Nen P R 1dz�tlx 'r o--. �h� - <br />State <br />1 <br />G <br />_s <br />5 <br />EPAiOtfirer <br />N <br />E <br />b. <br />stat" <br />`t <br />p <br />EPA/Other <br />T <br />O <br />a <br />v <br />R <br />C. <br />State <br />`'-��_ <br />EPAlOMer <br />W <br />d <br />Slate - <br />I - <br />w <br />EPA/Otlror <br />U <br />W <br />J. Addftml Desoriptims for Materials Listed Above <br />K Handling Codes for Wastes <br />Listed Above <br />Zo <br />a. <br />b. <br />W <br />C. <br />d. <br />Q <br />Z <br />15. Special Handling Instructions and Additional Information <br />a <br />i <br />J <br />U <br />16. <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br />J <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 />IL <br />national government regulations. <br />co <br />1 am a large quantity generator. I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br />IXIf <br />IX <br />to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the <br />present and future threat to human health and the environment; OR, if I am a small quantity generator, 1 have made a good faith effort to minimize my waste <br />> <br />U <br />generation and select the best waste management method that is available to me and that Ican afford. <br />W <br />Printed/dyped Name <br />Signature -- r Month Day Year <br />W <br />WT <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />Z <br />A <br />Printed/Typed Name _ <br />Signature Month Day Year <br />® <br />F <br />q;4. <br />W <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />Q <br />R <br />T <br />Printed/Typed Name <br />Signature Month Day Year <br />U <br />E <br />Z <br />19. Discrepancy Indication Space <br />F13, <br />NAWV-34, 0®?30( <br />A <br />C <br />1 <br />L <br />1 <br />Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />T <br />Y <br />r2O5.Facility <br />/Typed Name <br />Signature Month Day Year <br />e <br />0< <br />< <br />DHS 8022 A _ Do Not Write Below This Line <br />EPA 8700-22 <br />(Rev. 6-89) Previous editions are obsolete. v <br />WHITE: TSDF RETAINS <br />