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State of California-Health and Welfare Agency Department of Health Service! <br /> Form Approved OMB No.2050-0039(Expires 9-30-9t` ../ Toxic Substances Control Divis-- <br /> Please print or type. (Form designed for use on elite(12-pitch typewriter). Sacramento.Cal... <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Page 1y Information In the shaded areas <br /> Document No. <br /> WASTE MANIFEST of r is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> KoO3man Trucking a 8 , '7 7 <br /> 1340 Y.Charter War, Stockton, Ca. 94207 B. State Generator's ID <br /> 4. Generator's Phone <br /> b 5. Transporter , Company Name 8. US EPA ID Number C. State Transporter'aice 1 (3 A p ID <br /> h <br /> h a a 4 1 fi fi 7 a j D. Transporter'.Phone <br /> N200 1117111 11444- <br /> 7, Transporter 2 Company Name S. US EPA ID Number E. State Transporter'&ID <br /> F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10, US EPA ID Number G. State Facility's ID <br /> Hatinwies service C IA P 10 18 13 11 j6 16 1712 18 <br /> 13331 ■.H117 33 H. Facility's Phone <br /> Patteraan Ca. 95363 800 874 4444 <br /> 12, Containers 13. Total 14. 1 <br /> {T 11. US DOT Description(Including Proper Shipping Name,Hazard Claes,and ID Number) Ouantity Un" W este No. <br /> A�.1 //.. '' S ^ //�s p No. TYTypeWtivol <br /> LOU a.W E #9 Z p�J Q U S Li VI Y /I/D.J. 0*01-F State <br /> G <br /> N (�� r7 6! EPA/ h j <br /> ON RE b. 7 Ste <br /> A <br /> T EPA/Other <br /> N D <br /> R c State <br /> EPA/Other <br /> 1Wyy d. State <br /> O EPA/Other <br /> {y I <br /> D! <br /> J. Additional Descriptions for Materiels Listed Above K. Handling Codes for Wastes Listed Above <br /> 6 W 9�� a. b. <br /> W /4 <br /> _� � r <br /> Q <br /> J �O <br /> C .5,C 11415 e <br /> F 15. Special Handling Instructions and Additional Information <br /> 2 <br /> WGNViRONMENTAL HEALTH <br /> <p 17.1 _ _ <br /> V <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,Faulted,marked,and labeled and are in all respects in proper condition for transport by highway according to applicable International and <br /> Nmaterial government regulations. <br /> If I am a large quantity generator.I tartly that I have a program In place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> O to be economically practicable and that 1 have selected the practicable method of treatment,elorage,or disposal currently available to me which minimizes the <br /> present and future threat to human health and the environment:OR,if 1 am a smell quantity generator,1 have made a good faith effort to minimize my waste <br /> U generation and select the beet waste management method that is available to me ri that I can afford. <br /> Z <br /> Printed/T ped Name Signature Month Day Year <br /> euft SCK ) / / 0 <br /> Il. Transporter 1 Acknowledgement of Receipt of Materiels <br /> R <br /> F <br /> Printed/TypedNames V ex <br /> saw <br /> 5 Month Day Year <br /> gl R 18. Transporter 2 Acknowledgement of/�Receipt of Materials — — - <br /> L< T Printed/TName <br /> v oG Signature Month Day Year <br /> Z E <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certificates of receipt of hazardous materials covered by this manifest except as noted In Item 19. <br /> T <br /> y PriMad/Typed Name Signature Month Day Year <br /> DNS$022 A(1/88) Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAY <br /> To: P.O. Box 400, Sacramento, CA 958124)400 <br />