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State of Cain lth and Welfare Agency Department of Health services <br />Form orad OMB No. 20 9 (Expires 9- ` Toxic Substances Control Division <br />Sacramento. Ca lifornia <br />A-pitch <br />Please <br />print or typs. (Form designed for use on typewriter). <br />UNIFORM HAZARDOUS t. generator's US EPA ID No. Ma <br />2. Page I Information In the shaded areas <br />WASTE ANIFEST °" <br />of is not required by Federal law. <br />3. generator's Name and Mailing Address' <br />(. 19. <br />, <br />JIL <br />4. Generator's Phone (' /tj f / <br />5. Transporter 1 CompanymName 8. US EPA 1D Number <br />CCi <br />Tt>iariar'a � <br />? <br />7. Transporter 2 Co any Name 8. US EPA ID Number <br />a <br />. Desi gnateq Fecility N nd Sitto. iddrges ,. 10. US EPA ID Number i Stats FaoN y'a 1D � ar <br />ix< <br />Q <br />C'» y.., <br />:., <br />12. Containers 13. Total 14 <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) OuaMiy t <br />LL <br />� <br />Vole <br />No. Type Wt/V <br />A'A <br />E <br />, t, <br />N <br />E <br />R\� <br />b. <br />A <br />TAl <br />O <br />Rcc <br />IL <br />d. <br />ser y <br />II <br />i k <br />§ <br />J. Additional Descriptions for Materials listed Above *" w. <br />tkf <br />Fit <br />W <br />irk': <br />t <br />Its <br />18. Special Handling Instructions and Additional information <br />Z <br />GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping Weare <br />J <br />and are classified, packed, marked, and labeled, and are In all respects In proper condition for transport by highway according 4o applicable international and <br />national government regulations. <br />If i am a large quantity generator, 1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree IJhave determined <br />to be economically practicable and that 1 have selected the practicable meth of treatment, storage, of disposal currently available to me which minimizes the <br />present and future threat to human health and the environment; OR, R I am a small quantity generator,have made a good faith effort to minimize my waste <br />generation and select the best waste management method that is available to me and that 1 can aff <br />Prirltad/Typed Name <br />Signet 77 00.r Month Day Year <br />p� <br />WT <br />17. Transporter I Acknowledgement of Receipt of Materials <br />Q <br />R <br />A <br />N <br />Printed/Type Name__ �- <br />_ _ <br />) ) <br />a Math Day Ysa <br />IS <br />,, e , I e <br />�.` <br />yt <br />P <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />T Printed/Typed <br />Name <br />Signatwets Monts Day Year <br />U <br />E <br />19. Discrepancy <br />a trt' Indication Space Nam and Wiling Address should ® l (213) 267-5492 <br />A <br />5200 Shlela <br />Las Angeles, Gk 90044 <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest a ds noted in Rem 19. <br />' <br />T <br />Y <br />P /Typed Name <br />Signet Month Day Year <br />Fes% f 7_1 t, <br />r" _ <br />DHS 8022 A (t /88) Do Not Write Below This lute Yellow: TSDF SENDS THIS COPY TO GENERATOR d DAYS <br />EPA 8700--22 <br />(Rev. 9-88) Previous editions are obsolete. l i <br />