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elate of l.alrfomra—Health and Welfare Agency a.v� <br />OMB No. 2xW-0039 <br />' rch \ • S -/e-73 <br />(Evorres 9-3091) <br />Form designed for use on elite ( <br />Please print or type t2 <br />See Inshuetions <br />- t)pewriterj <br />on 0 A of Rage 6. <br />F Trarnoortet's Phone <br />G stoTF�,k s 3'11 6 <br />itis <br />Signanxe <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1•GenerctorsUSEPA IDNo. 1 <br />G AI Df 91 81 11 <br />west. Np. 2 Poge I <br />�' �, °- 1 <br />q <br />3. Generaors Nome and Maiing Adaess <br />H <br />444:4 <br />1 I i I of 1 <br />11. US DOT Description (irciuding ProPer Shipping Name. Hazard Coss• and ID Number) <br />A State McwAest.Documer <br />S"�• r f) r �+ t►td .'0y i i7iC f<T'd^ f" t t'ai <br />14 Unit <br />d Generpt0(s Phone ({�'j) 6 7► <br />"t / <br />y r. <br />S �•�ilY.cil1 <br />B. Stere 6enerotor s ID <br />5. Tra,sporter i Comparny Nave <br />PRC PATTERSON, INC. <br />6. US EPA op Number <br />13tE <br />C Stop®Ttorxpotters fD ., <br />Quant <br />C IAI D 19 i 8 1 <br />I 6 I 9 t 6 14 I2 I 0 fl:T,,sPoers Phpre <br />1. Transporter 2 Company Name <br />8 US EPA ID Number <br />f :Stgle,Traspottat a Id <br />Deportment Of Health Sere; <br />Toxic Substances Control P(ogror <br />Sacramento. Colifornic <br />Irdormasforn is the shaded seas <br />is not reamed by Federal low. <br />rc? <br />T <br />9' K;10. <br />dress <br />� 'W <br />33 N HWY� 3 <br />O <br />I 1 f I i I 1 1 i I I <br />US EPA ID Number <br />F Trarnoortet's Phone <br />G stoTF�,k s 3'11 6 <br />CO <br />Signanxe <br />PATTERSON, CA 95363 <br />N <br />C ID 10 18 13 11 16 16 17 12 I $I4 <br />t h 1 <br />H <br />444:4 <br />P <br />11. US DOT Description (irciuding ProPer Shipping Name. Hazard Coss• and ID Number) <br />12. Contwrers <br />13. Total <br />14 Unit <br />Ja <br />�V <br />Mted/Typed Nave <br />v �t <br />Lu <br />No. <br />T <br />Quant <br />wWol <br />R <br />T`Z <br />Y"? p <br />E'7 <br />N <br />E <br />b <br />ill01/ <br />1/ <br />'''�7� <br />1 i /Ie -d <br />l., <br />A <br />L <br />I 2Q <br />T Printed/Typed <br />FOCdity Owner of Operate C®Rdk:atlon of rw e' ur materials Covered by this n <br />Name <br />Y <br />signah,re <br />/C <br />\ `j <br />R <br />,-1 <br />07)U <br />A <br />CO <br />® <br />a <br />aaoo <br />d <br />i I <br />1 <br />I I 1 1 <br />V <br />N <br />J Addrtaru�l DescropFars for AAOtenr� LatedAbove' . . <br />y r <br />aHanding Codes. foriMostes.Lktod:Ab <br />Z <br />u r <br />.Specie Handling Irstn,criors and Additbrcq Intomation <br />N 24 HR. EMERGENCY CONTACT: PRC 1-800-874-4444 <br />Q. <br />24 HR. EMERGENCY CONTACT: CHEM TEL INC. 1-800-255-3924 <br />c APPROPRIATE PROTECTIVE CLOTHING 6 RESPIRATOR <br />J <br />Z16. GENERATORS CERTIFICATION: I hereby declare that the content of itne consignment ere fully aid occuratety described above by Proper shippng name and nae classified. <br />O piked. marked. and labeled. a d are n of respects in proper condition for transport by highway cccorzing to applicable international and national government m7"iorx <br />Q if 1 am a large quantity generator. I certify that i have o ran in <br />ec Wog place to reduce the volume and tonicity of wame generated to the degree 1 hove determined to be <br />Z <br />ono—coy Practicable and that I have selected the Practicable method of treatment. storage. «deposal currently available to me which ninvrees the present aid future <br />4tneept to htxsnarn health and the environment; OR. / t an o srtoN Quantity gator. I have mode a good faith effort to mnimize my waste generation and select the best waste <br />management method that is available to me and that i can afford <br />..+ <br />Q Prnted/ryped Nome Signahve <br />A'- <br />a - <br />C <br />T <br />17. Tnarsporter 1 Acknowledgement <br />dgement of Receipt of Materiae <br />O <br />R <br />Prnted/ryped Nome <br />Signanxe <br />V <br />N <br />z <br />P <br />O 18. <br />R <br />1 r0i"doorter 2 Ackrowle meat of m, i t of Materials <br />Mted/Typed Nave <br />Lu <br />T <br />E <br />S e <br />�r <br />O <br />R <br />ix <br />Q <br />U <br />F 19. <br />Dacrepa,ey hdication space <br />A <br />L <br />I 2Q <br />T Printed/Typed <br />FOCdity Owner of Operate C®Rdk:atlon of rw e' ur materials Covered by this n <br />Name <br />Y <br />signah,re <br />/' � <br />DO NOT WRITE BELOW THIS LINE. <br />DHS 8022A (12/90) <br />EPA 8700-22 <br />item <br />i/12-I!I�p <br />i 12..1 IF -1 <br />Month Day year <br />Cg i�9a1 <br />White: TSDF SENDS THIS COPY TO DHS WITHIN 30 <br />To: P.O. Boz 3000, Sacramento, CA 95812 <br />