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State of California-Health and Welfare Agency Department of Hr�i Se—,s3 <br /> 'Form Appril OMB No.2050-0039(Expires 9.30.9 Toxic Substances Control Division <br /> Please print or type. (Form designed for use on elif pitch typewriter). Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. <br /> a� ^ Manifeat 2. Page I Information In the shaded areas <br /> WASTE MANIFEST CO 0 / ✓ / (/Q oof / is not required by Federal law. <br /> 3. G e tyr's Na a and Maili99pp Addreea A. State Manifest Document Number <br /> (� .> �s4�,E/1() K16CC "Aj-r,1(-WAST, s4. f <br /> 92 <br /> j 10 5 o W. -.,+V f(- /3c✓�. <br /> T/(A-C Yr C14 B. State Generator's ID <br /> 4. Generator's Phone"9)far-2193 <br /> w <br /> S. T/r/pnepor/ter 1 Company Name 8. US ErP±A ID Number C. State Transporter a ID 0 <br /> n /\� Transporter'a Phone &C - - <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> Oo1 1 1 1 1 1 1 1 1 1 1 1 F. Transporter'.Phone <br /> 1 9. pesjZed Wa ill Name and.S�R dress 10. US EPA ID Number O. State Fg ility'e ID <br /> a //�(� cc <br /> .i63'iV/✓, t7WY1,33 �� y <br /> C% f -T%�S 0,V,CR �" LJ �p �O / H. FaFOO-ei <br /> 'P7y- y `�y <br /> a* 12. Containers 13. Total 14. 1. <br /> N2 11. US DOT Description(Including Proper Shipping Name,Hazard Claes,and ID Number) Ouantity Unit Waste No. <br /> s� No. Type Wt/Vol <br /> � , U state /3 <br /> E /`I B 14-4 VA F1? 9 O / T, / EPA/Other <br /> N V/�i'!rr 's' / 47 <br /> =N R b . State <br /> A <br /> CP T EPA/Other <br /> V O <br /> ppa R C. State <br /> m EPA/Other <br /> W <br /> it. State <br /> F <br /> 2 <br /> W <br /> O EPA/Other <br /> w <br /> rn J. Atlditignet De tions fo�r e�ta�dd a LI t d Ab v� �� ""�� a. HandlingCodes for Wealea Listed Above <br /> 0 A 3= - sd uo-- <br /> O e. D. <br /> /'T r G C. it. <br /> J <br /> Q <br /> Z <br /> O <br /> F 16. Special Handling Instructions and Additional Information <br /> Q <br /> 2 <br /> J <br /> J <br /> U 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 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 /> a national government regulations. <br /> W <br /> 5IT <br /> If I am a large quantity generator,I certify that I have a program ti place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> Opr s economically predicable and that I have selected the practicable method of treatment,storage,otor,or disposal currently available to ma which minimizes the <br /> present and future threat to human health and the environment;Is a it l available <br /> a smell quantity generator,I have made a good faith effort to minimize my waste <br /> O <br /> generation and select the beat waste management method that la evaikble to me and that I can afford. <br /> all Printed ITTyyped Name Signature Month Day CYea15 <br /> rQ <br /> '/ n.✓F,1lh. '��Q / <br /> gW17. Transporter 1 Acknowledgement of Receipt of Material. <br /> LL8 Print p �m /s C Signature 1� Day Year <br /> O P IV/� J 7Q <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> G T Printed/Typed Name Signature <br /> Month Day Year <br /> O E ii <br /> 2 <br /> 19. Die cr pancy Indication Space <br /> F <br /> A <br /> C <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T <br /> y Printed/Typed Name SMonth Day Year <br /> ignature <br /> DHS 8022A(IY88) Do Not Write Below This line <br /> EPA 8700-22 Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (Rev.9-88)Previous editions are obsolete. <br /> To: P.O. Box 400, Sacramento, CA 95812-0400 <br />