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Healt <br /> 1afe of California—Health and Wegare Agency Da Substances <br /> o1 Control Service:. <br /> w Approwiti OMB No.2050-0039(Expires 9-30-88) Toxic SubatSacr a mento. Division <br /> Sncrnmenlo,Cnlilonu.I <br /> 9rase rah w 1 e. Foran desi netl Iw use on*file 12 ewriler. <br /> A UNIFORM HAZARDOUS 11. Generator's US EPA ID No. Manifest age 1 Information in the shaded areas <br /> Document Noof is not required by Federal law. <br /> WASTE MANIFEST ,- <br /> 3. Gtneiator's flame and Mailing Address A. State Manifest Document Number <br /> I„ <br /> 1 B. Stale Ganeubr'a I <br /> a. Generalor's Phone k - <br /> / <br /> e. Transponer 1 Company Name 5. US EPA•ID Number C. Stale Trona ortei s ID <br /> / ! I 1 r` D. Transporter's Pho - y (,C, <br /> r 1 ra <br /> 7. Transporter 2 Company Name B. `US EPA ID Num mer E. Stale Transporter' D <br /> 'I h . Tran.Poner'a Phone' 1 <br /> 9. Deeigneled Facilily'N flue and Sile Atldresa 10. U/S 1/ ID Number G. Slate Facility's ID <br /> ✓� Fa Ility's Phone - <br /> 12. Containers 137 Title 14. 1. <br /> 11. US DOT Description(Including Proper Shipping Name.Hazard Class.and ID Number) Ousntily Unit Waste No. <br /> No. Type WI/Val_ <br /> Stale <br /> // <br /> G a �1�(• 1.2J/)1�li_a4 / b/L C/,6LA� EP /Ot w <br /> E I <br /> N <br /> F b. Slate <br /> H <br /> A EPA/Other <br /> T <br /> O c State <br /> H <br /> EPA/Other � <br /> d State <br /> EPA/Other <br /> J. Additional Descriptions for Materials Listed Above aK. <br /> . Handling Codes far Wastes Listed Above <br /> e, b. <br /> y; aL1 / d. <br /> r � , I r t��' ♦ r r <br /> 15. Special Handling Instructions and Atlditional Information <br /> it <br /> 18. <br /> GENERATOR'S CERTIFICATION: I Hereby declare that the contents of this consignment are lolly and accurately described above by proper shlpph' <br /> name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applic., <br /> international and national government regulations. <br /> II I 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 I h +c <br /> determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently avadabto <br /> me which minimizes the present and future threat to human health and the environmenl; OR. if I am a small quantity generator, 1 have made a g/od <br /> faith effort to minimize my waste generation and select the beat waste management method that is available to me end that 1 can afford. <br /> Prinl°d/TY d me Slpnadure Month Day Year <br /> I/e I <br /> / t <br /> T 17. Tra -order 1 Ackinowledgemallift of Receipt of Materials <br /> RMonfA Day Yeer_ <br /> A Printed/Typetl ma //, <br /> / Signature / <br /> SC. <br /> / / <br /> p18. Tmnaporler 2 Acknowledgement its Receipt of Materials <br /> R <br /> g Month Day Year <br /> Printed/Typed Name BI helots <br /> E <br /> 19.buscrepancy Indication Space <br /> F <br /> A <br /> C <br /> L <br /> 1 20. Facility Owner or Operator Codification of receipt of hazardous materials covered by this manifest except as noted In hem 19. <br /> g <br /> � Printed/Typed Name Signature Month Day Year <br /> ,IS 8022 A(1/87) INSTRUCTIONS ON THE BACK <br /> 'A 0700-22 YELLOW: GENERATOR RETAINS <br /> lay.9-88) Previous editions are obsolete. <br />