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% Department of Health Services <br /> ,e—i/eellh and Welfare Agency Toxic Substances Control Division <br /> JM8 No.2050--0039(Expires 930-90 Sacramento,California <br /> type. (F..designed for use on M.(12-pltdryp--Hee). <br /> 1NIFORM HAZARDOUS Oenerel e US EPA ID No./ ��� Manliest x. Pepe t is no,required <br /> In the shaded erects r <br /> ° of / Ie not required DY Federal few. L <br /> WASTE MANIFEST <br /> P A. stele Menl99oYbSeerelorMailing Atldrees <br /> l/.-8 n `�C�� 8. State Oener•lor'•ID <br /> a, oenerelor'e Phone(� yp /•!? f <br /> Tr nap odair 1 Company a 6. U EPA ID Number C. State TreNpaHei•ID <br /> D. Transp�er,@ Phone <br /> v� 2. Transporter 2 Company Name <br /> B. N U9 GEPA ro nnVmber jr, Stele Trensporter'a 10 - <br /> F. Trenepodsis Phone <br /> eeipnet d Facility Non" Slle Ads.... 10. U9 EPA ro Nember G. Slate FeolptY'a ro <br /> 4. <br /> u S > jDaAA <br /> � . <br /> T / 0 9 " 1�I%',97 <br /> a QhgB•�� <br /> Z 12. Containers 13. Total N. I. <br /> ¢O Quantity Unit Wst1 No. <br /> 0 11. U9 DOT Description(Including Pro er Shlp g Nem.,H.rard Class,end ro Number) <br /> No. Type Wt/Vel <br /> ] Stale tI <br /> Q e r? <br /> u <br /> N � / 9 O P EP l <br /> 3 state <br /> aQ E b. <br /> 5 R <br /> A EPA/OTher <br /> T <br /> e O stele <br /> v R c. <br /> FPA101nor <br /> State <br /> d. <br /> 2 t EPAIOIf K <br /> W <br /> U <br /> W K HendMflO CO&S fm WMIIN LIMed A6ov► <br /> W J. Iflonal Oestri Ions[orr ate/(lots/Li�stQ�'I�A 0 �40t'a � �' l '�•( ,> •rTr"`iT>E1N'R�MIeh,`Ek '13f{i u I e <br /> Z <br /> VV JDZ �► <br /> Q <br /> 15. special Henal g Inelr. Ione and Additilnlwmtllo tel t ►}p/al,I l./ <br /> UIP rr IMI -6 P Arte c T I vIF CLV.TF+ �I �J real <br /> . <br /> v <br /> 1e. <br /> J GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> pplic•ble International end <br /> and ere classified,pecked,marked,and labeled,and are in all respect,M proper condition for transport by highway according to e <br /> Nnational government regulations. __ - <br /> I1 I am a large quantity generator.I certify that I here a program in place to reduce The volume and Iozicil axle gepmaled to the degree 1 have determined <br /> to be economically practicable and that I have selected the practicable method of treatment,storagElQppul currently available to me which minimizes the <br /> present and future threat to human health and the environment;OR,If I am a smell quantity geper•TSF. • Medd6 a good faith effort to minimize my waste <br /> Q generation and @elect the beet*Asia management method that is available to an and 1 1 I can a—TTFFe <br /> Z Month Day Year <br /> W Printed/Typed Name / �, � Slow.,. <br /> w <br /> T 17. Transporter 1 Acknowledgement of Recaipl of Materials <br /> R <br /> APtM1 Ne a "no • Month DAY year <br /> LL afLLe2 �� 9 <br /> O P IM 0t6. Trane oder 2 Acknowledgement of Receipt of Materiel- , <br /> I <br /> q R Prinled Hyped Neme Signet a Month Day Year <br /> O E <br /> Z <br /> IB. Dlecrepancy Tndlc.tlon Specs <br /> F <br /> A I <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Ce"Iftalion of receipt of hezardoue materials covered by Ibis maniteat excepl as noted In Item 19. <br /> T Month Day Year <br /> y Printed/Typed Memo 81g081ore <br /> DHS 6022 A(I188) Do Not Write Below This Line <br /> EPA 871)D-22 Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (Rev.9-8s)Previous edition.ere obsolete. <br /> it To: P.O. Box 100, S«rgmenlo, CA 95812 OAOO <br /> - - _ ____.- - - - --- <br />