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Slate of California -Health and Welfare Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-91) <br />ata- n, <br />Department of Health Services <br />Toxic Substances Control DIVISIOn <br />Sacramento, California <br />• <br />.1ease <br />pr <br />o .rYv. ,. v.... vvn.v..vv .v ....................- ..i I . . . . . _... <br />'yUNIFORM HAZARDOUS 1. Weralor's US EPA ID No. Manifest <br />-e'. Pepe 1 ''ation in the shaded areae <br />Inform <br />Document No. <br />WASTE MANIFEST <br />of is not required by Federal law. <br />3. Generator's Name and Meiling Address - L N6ri6 <br />/bol e�at.��..- Vji,Ta•vl � <br />�. , <br />4. Generator's Phone (eaiq <br />02 <br />6. Transporter 1 C6ritpeny Name e. US 5PAdD Num e[ c <br />SA. Aka / 421 lr .001.14 <br />„Traneporlet'e bona �. _:;. <br />P US <br />T. ransporter 2 Company Name EPA ID Number <br />tate Transporter <br />F..-: Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID ' <br />die �Jaa D. / t nt fin., <br />�Li�l rl it ifi I r� <br />__IL <br />H. Facility's e <br />yP�hyon <br />AS" <br />W <br />12. Conte iners <br />13. Total <br />14, <br />L <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity <br />Unit' <br />Waste No. <br />No. Type <br />Wt/vot <br />State <br />e. <br />Z <br />EPA/Other <br />G <br />ns�kill <br />E <br />b. <br />State <br />R <br />EPA/Other <br />A <br />T <br />O <br />R <br />a <br />Slate <br />�.` <br />s <br />EPA/Other <br />d <br />State <br />EPA/Other <br />J. Additional Descriptions for Materiels Listed Above <br />K. Hendlinp Codes for Waetae <br />Listed Above <br />Co�T.I 17yst G'ow,cti •f R1 rnw T%cn- <br />C. <br />d. <br />t <br />sb <br />16. Special Handling Instructions and Additional Information ,//� j d e <br />J <br />19. <br />i <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of i p�u)1C` ppurately described above by proper shiPPingname <br />and are classified, packed, marked, and labeled, and are In all respects (1'�p{p1'd�'r�' MY highway according to applicable International and <br />_ <br />is <br />national government regulations. <br />r <br />If I am a large quantity generator, 1 certify that 1 have a Q�(9'place to reduce the volume and toxicity of wears generated to the degree 1 have determined <br />to be economically practicable and that I have selected t icable method of treatment, storage, or disposal currently available to me which minimizes the <br />7 <br />present and future threat to human health and the environment; OR, If I am a email quantity generator, I have made a good faith effort to rItalmize my waste <br />generation and select the beat waste management method that Is available to me and that I can Hord. - <br />Print /Typetl Neme .... <br />Signature Month Day Year <br />y <br />—7,L L l.. <br />/ <br />U T <br />17. Transporter 1 Acknowledgemilint of Receipt of Materials <br />R <br />A <br />Printed/Typed Name j s"-` - <br />Slgnelure - Month Day Yeer <br />N <br />i <br />S <br />P <br />18. Transporter 2 Acknowled lint of Materials <br />. <br />n q <br />= T <br />_ <br />Printed/Typed Na , i <br />Signature Month Day Year <br />E <br />.... _ <br />L_ <br />19. Discrepancy Indication Space <br />F <br />A <br />I <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />Printed/Typed Name <br />Signatures - Month Day Year <br />r <br />DHS 8022 A 01 88) <br />EPA 8700-22 <br />(Rev. 9-88) Previous editions are obsolete. <br />Do Not Write Below This Line <br />Blue: GENERATOR SEND$ jHIS COPY TO DOHS WITHIN 30 DAYS <br />To: P.O. Box 400, Sacramento, CA 95812 0400 <br />