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Furm Mraoved OMB No 2J.o-0039(Enpne,aSOh <br /> Pleeae net ort Form dao- red for ase on elite itch! ewotis) NNWSac;nrnentu,C,litumia t <br /> UNIFORM HAZARDOUS I. Generator's US EPA 1D No. Manifest 2 Page I Information in the shaded areas <br /> C. Document No. of is not required by Federal law. <br /> WASTE MANIFEST <br /> 3 Gr�e�N/�(1na ed Mailing A1ddreae A. State Manlleal Document Humber <br /> ;77 t �Ff �ZJ1e /n1 / /L�/./x <br /> ( p B. State Geruroyor'a ID <br /> 1Generator',Phone(z_v.J) C , / <br /> (/ /_ / <br /> C. <br /> p 5 Transporte(1 ompa Name / 6. US EPA ID Number C. Stale Tranaporter's ID <br /> N <br /> va <br /> J �' D. Trenapoder'c Phon <br /> (F'r /' <br /> N 7. To naporler 2 Company Name e S EPA ID Number E. Stets Tranapodiye ID <br /> '9 W Dasignalea Faci ity Nam,and Site I dress 10. US EPA 10 Number G. State Facility's I <br /> U <br /> H. acility's Phone <br /> z <br /> ¢ 12 Gonlei rs 1 Tot e1 11. I. i <br /> C t t. US OOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) -- Quantity Unit Waste No. <br /> t� No. Type WI/Vo <br /> ¢ Stale, <br /> EEPA/Other <br /> r N ( <br /> 3 E b. State <br /> N R <br /> m A EPA/Other t <br /> P T (/I4 <br /> v O j <br /> e R e. (//N�� State <br /> EPA/Othm <br /> ¢ d. State I <br /> W <br /> W <br /> EPA/Other <br /> U <br /> w <br /> m d Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> _z e. b. <br /> C <br /> a <br /> y <br /> W <br /> ¢ c d. <br /> J <br /> Q <br /> 2 <br /> 0 <br /> r 15. Special Handling Instructions and Additional Information <br /> a <br /> 2 <br /> W_ <br /> F <br /> J <br /> Q 6. <br /> U GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are bully and accurately described above by proper shtppi, 1 <br /> name and are classified packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable 1 <br /> international and national government regulations. j <br /> E -I am a large quantity generator. I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree have t <br /> ¢ determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to ( <br /> O 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 /> T faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. <br /> U <br /> 2 Print yp it Name Signature Month Day Year <br /> �. Y <br /> W <br /> 2 T 17. Transporter / Acknowledgeme t of Receipt of Materials <br /> w R <br /> 2 A Print�Typ d Name / Signature Month Day Year <br /> < N <br /> LL <br /> O PO 18, Transporter 2 Acknowledgement n Receipt of Materials <br /> W A Printed/Typed Nama Signature Month Day Year <br /> a E <br /> U <br /> ? 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 20- Facility Owner or Operator Certification o1 receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> V Printed/Typed Name Signature Month Day year <br /> I I I i I i <br /> DHS 6022 A(1/67) INSTRUCTIONS ON THE BACK <br /> EPA 6700-22 Where: 1SDF SENDS THIS COPY TO DOHS WITHIN 30 DAY") <br /> (Rev.9-88) Previous editions are obsolete. <br /> L b°G. Bo= 30'J0, Socramenlo. CP 95P 13 <br />