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State of Ca h and Welfare Agency AM <br />Form roved No. 9 (Expires S <br />Please print or type, (Form designed for use on ei . <br />J3. UNIFORM HAZARDOUS <br />WASTE MANIFES[ <br />Generator's Name and Mailing Address <br />4.Generator's Phone ( r(.'6) <br />8. Transporter 1 Company Name <br />T. Transporter 2 Company Name aX <br />1 Department of Hearn Services <br />` IX� Toxic Substances Control Division <br />f-pkch er). Sacramento, California <br />Generator's US EPA ID No.Manifest 2. Page 1 Information In the shaded areas <br />Document No. <br />I Al LA 41 P `99of Is not required by Federal law. <br />M"M�i vv °� A. to <br />677& 11FASURNANC,13. State Goneratoes <br />8. US EPA ID Number C. state <br />C� f�. T a, < <br />a. US EPA ID Number E. Steira 1 <br />9. Designated Facility Name and Site Address 10. US EPA ID I <br />own i9,./oji g< <br />V49 t <br />NIL <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />//��yy�� to a i, <br />Vim � <br />E b. <br />N R t <br />A �to <br />'" +7t' <br />To <br />mow G Stetfga ,64,P <br />If <br />H. Facilfty'a.f'h+l <br />12. Containers 13. Total 14. <br />Quantity Unit <br />No. I Tvoe wt / v <br />a <br />M <br />,t: AdtHt ions for Materials Listed Above - , K. <br />Ham Codes Wort L1steA <br />, <br />16. Special Handling Instructions and Additional Information <br />B . 10. <br />J GENERATOR'S CERTIFICATION: i 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 and <br />national government regulations. <br />If 1 am a large quantity generator. I certify that I have a program In place to reduce the volume and toxicity of waste generated to the degree 1 have determined <br />to be economically practicable and that I have selected the practicabWmethod of treatment, storage, or disposal currently available to me which minimizes the <br />} {resent 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 />C� generation and select the best waste management method that is available to me and that I can afford. <br />Printed/Typed Name Signature Month Day Year <br />fU <br />yj T 17.Transport—or 1 Acknowledgement orAeceipt of Materials <br />A Prin Typed Name r Sig ® Month Day Year <br />N <br />O S7-154 to <br />P <br />O 18. Transporter 2 Ack wle gement of Receipt of Materials <br />W <br />UT Printed/Typed Name Signature Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />L <br />I 20. ci1Hy Owner or Oper for Certification of receipt of hazardous materials covered by thl nifest except as noted in Rem 19. <br />Yed /Typed acne Signature Month Day Year <br />DHA 8022 a (1 sa) Do Not Wri Below This line <br />EPA 870e--22 Yellow: TSDF SENDS THIS COPY40 GENERATOR WHIN 30 DAYS <br />(Rev. 9-88) Previous editions are obsolete. <br />