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11 <br />i <br />State of California --Health and Welfare Agency <br />Fcrni AppOved OMB No. 2050--0039 (Expires 9-30-81? <br />Pd ad t e on elite itch <br />Department of Health Services <br />Toxic Substances Control Division <br />Sacramento, California <br />is as print to <br />ort e. (F ons ea n us <br />UNIF$)RM HAZARDOUS 1. Generator's US EPA ID No. Manifest <br />Document No. <br />2. Page i Information in the shaded areas <br />of % <br />WASTE MANIFEST C Q d 4 3 17 fp� <br />is not required by Federal law. <br />3. Generator's Name and Mailing Address <br />/ZocmcoN IWZ2 f t/Llaw-� <br />A. State Manifest Document Number <br />87434644 <br />e -%A ch <br />B. Slate Generator's ID <br />6. Generator's Phone <br />5, Transposer 1 Company Name 8. US EPA ID Number <br />C. State Transporter's ID <br />D. Transporter's Phon <br />581-10 R V y G •�� <br />7. Transporter 2 Company Name 8. US EPA D Number <br />E. State Transporter's 10 JIM6 <br />F. Transporter's Phone <br />9 Designated Facility N me d Sita Ad ress 10. US EPA ID Number <br />�t tJpJC� <br />G. State Facility's ID <br />/�f ¢- H S %R <br />d O <br />uN <br />k)' 46rf f 7 <br />H. Facility's Phone <br />A/14019 <br />`/j i i b 3' 49'3-7- <br />9 ' C 9 u <br />12. Containers <br />13. Total <br />1a. <br />1. <br />11, US DOT Description (Including Proper Shipping Name, Hazard Class. and ID Number) <br />No. Type <br />Quantity <br />Unit <br />Wt/vo <br />Waste No. <br />/� <br />W#5Te COMB✓S/i(3<r A11"1 0 lv4 S_ <br />rnol <br />Stat`/ <br />E <br />G� <br />EeJ r <br />/Othe�� <br />N <br />' <br />E <br />b. <br />vicR <br />St <br />A <br />EPA/Other <br />T <br />O <br />c. <br />State <br />R <br />l'h <br />EPA/Other <br />d. <br />State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />� GU/9� D.-�C 9NtY <br />K.Handling Codes for Wastes <br />a. <br />Listed Above <br />b. <br />aI <br />c- <br />d. <br />-Tj JVAol 16�-V Wes.dtun'4 <br />ty <br />15. Special Handling Instructions and Additional Information <br />e <br />1e <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment aie fully and accurately described above by proper shipping <br />i <br />name and are classified, packed marked, and labeled and are in all respects in proper condition for transport by highway according to applicable <br />international and national government regulations. ' <br />1 <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 I have <br />I have the method of treatment. storage, or disposal currently available to <br />determined to be economically practicable and that selected practicable <br />me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator. I have made a good <br />faith effort to minimize my waste generation and select the best waste management method that is available to me and that 1 can afford. <br />Printed /Typed Name � <br />Signature Manfh Da Yeer <br />D <br />,a,7`— ✓OiY1 G <br />l <br />mi T <br />R <br />17, Transporter I Acknowledgement of Receipt of Materials <br />A <br />P' /Typed Name Sign urs Month Day Year <br />S <br />I ie�-cRSonl <br />) P <br />O <br />8. Transporter 2 Acknowledgement of Receipt of Materials <br />,l <br />r R T <br />Printed /Typed Name <br />Signature Monts Day Year <br />E <br />19, Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />20. Facility Owner or Operator Cottion of receipt of hazardous materials covered by this manifest except as noted - 19. <br />T <br />Printed IT N e <br />Signature Month Day Year <br />V <br />DHS 8022 A n /87) White: TSDF SEND IS COMM DO WITHIN 0 $AYS / TRUCTIONS ON THE BACK <br />EPA 8700-22 To: P.O x 3000, Sacramento, CA 95 12 <br />(Rev. 9-88) Previous editions are obsolete. <br />