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EPA 8700--22 <br />(Rev. 9.86) Previous editions are obsolete. <br />IN CASE OF AN EMERGENCY OR SPILL, CALL THE NATIONAL RESPONSE CENTER 1f , -424-8802;,WITHIN CALIFORNIA CALL 1-800-852-7550 <br />M -11,11 <br />AI, AP�. <br />Welfare of Gnoy <br />aifoie <br />` Approved NO <br />of H"Ith Services <br />Toxic Substances <br />P <br />print or t F net <br />Sacramento, California <br />1. rator's US EPA 10 No. nifest <br />UNIFORM HAZARDOUS <br />fr 1 <br />No. <br />`ATE <br />MANIFEST <br />3. Generator's Name and Mailing Address <br />Santa re lailvay Coo � <br />�•��.ate ., �� �' � ��°�w <br />Diancin1d & 1• Werth h 5 tr"ka �t�� 21� s� '� •� 9.120� <br />4. Generator's Phone ( ) <br />e <br />5. Transporter 1 Company arae t&. ^US EPA ID <br />7. ansp&ferfdompany Name :,,+ 8. US EPA ID Numberr <br />,M s <br />9. Designated Facility Name and Site Address :I 10. US EPA 10 Number( <br />Skate f+ <br />r f <br />Chemical Waste Management, �� <br />� ` V - <br />... <br />, <br />bow <br />Ket CiCo. �► 4 <br />Baa <br />to g, <br />12. Containers 19. Taal <br />14.17 <br />*, <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and 10 -Number) <br />Ouantity <br />Unit,'r <br />t#11l <br />No. <br />Type <br />1V <br />. <br />a Waste Oil Contaminated Debris <br />� � <br />G <br />E <br />.til � Vast aF`ey '`,• - t h 4 k <br />+� �} yw � dx � fid, � � � �lfi* <br />TAt <br />N <br />E <br />R <br />b.. <br />{aq. <br />A <br />T <br />.yam s <br />a <br />E? <br />C. <br />r< . <br />d. <br />�Y 4y 2 X' a "� 7 b d` <br />� ,,�yrr ✓ f <br />rS <br />rk <br />Oil—h�� <br />16. Special Handling Instructions and Additional Mf <br />clew" • safety Glasses� >+� �p�• � tin n 870 "2195-030 w <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by propgr shipping <br />name and are classified, packed, marked; and labeled, and are in all respects in proper condition <br />for transport by highway according t6 applicable <br />international and national government regulations. <br />If I am a large quantity generator, i certify that I have a program in place to reduce the volume and <br />determined to be nomically icabie at►� t I have selected the pra"gable of treatment, <br />toxicity of waste generated to the degree I have <br />storage, or, t�is�q f �agnjly, available 40 <br />:" <br />pry <br />me wliieh iHani i _,-press�Sf; �oature ttir humawheal4h $nd th8 e m OR, i Il am a small quantity g(fnera or, jhave,made a good <br />_faith effort to minor a rtiy *waste ation and,salact the`best waa4e mane ant m that is available <br />to rn® $fid ll°iaf'"Lahfbgr <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />R <br />17. Transporter 1 Acknowledgement of Re t of Materials <br />A <br />N <br />Printed/Typed Name , <br />Signat" <br />p <br />, Month Day Year <br />S <br />j <br />r <br />yp <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />:. <br />F <br />A <br />19. Discrepancy Indication Space <br />C <br />20. Facility Owner or Opera4or: rtification of receipt of _N. rdous materials covered by this manifest except as noted in ftem 19. <br />{. <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />Y <br />I <br />DHS 8022 A (1/87) YEU.OW- GENER OR RETAINS <br />INSTRUCTIONS ON THE BACK <br />EPA 8700--22 <br />(Rev. 9.86) Previous editions are obsolete. <br />IN CASE OF AN EMERGENCY OR SPILL, CALL THE NATIONAL RESPONSE CENTER 1f , -424-8802;,WITHIN CALIFORNIA CALL 1-800-852-7550 <br />