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Slate of Gal,lorma—Health and Weller.Agency Department of Services <br /> Forth approved DMO No.2050-00340 -96)(Expires 9-30Toxic SubstancesCConteontrol Division <br /> Sacramento.California <br /> poll tint or. e. Form des had for ase on elite 119 - h t -writer. <br /> UNIFORM HAZARDOUS Generator'.US EPA ID Na. r r Manifest 2. Paige 1 Information in the shaded areae <br /> Dar: ent Noof is not required by Federal law. <br /> WASTE MANIFEST a12. <br /> 3. enraltor' Neme end rPding Address A. State Mountain Document Number <br /> WV/&>A'(19Vy-41 87685809 <br /> .;l(P+D C^nq 74)V ;PAA--v0 40'z Pf",t{av, B. State Generalities ID <br /> 4. Generator's Phone !`) uZ <br /> S. Transporter I Company Name 6. US EPA ID Number C. Slate Tranaporter's ID <br /> V. Transp,xl e.Phone _ <br /> J 7 Transporter 2 Company NtRmO a. US EPA 10 u p er E. State Tnnepo lee•ID <br /> F. Transporter's Phone <br /> J 9 Designated Facility Name and Site Address 10 US EPA ID Number G. Slat.Fecll"'s 10 <br /> ILN-ij SG,p7 SE,et#cs <br /> 1 ^�2/, CC / Ju(I 6 DLL9QA-us1 H- Facility 3 Phone <br /> :54 - � / <br /> y -I/ls <br /> icedye <br /> 12. Container 13. total 14. I. <br /> tl. US DOT Description(Including Proper Shipping Name.Hazard Class, and ID Number) Ouentity t/V Waste No. <br /> n /� / �(�/ �+ No. Type WI/VoState <br /> G a �M �G,/�L �IU 1� Gd' I/JC, /� EPA tie <br /> E I'ti/fj D O Q 64 <br /> N <br /> E n State <br /> R <br /> A EPA/Other <br /> T <br /> O c Stets <br /> R <br /> EPA/Other <br /> it State <br /> 10 <br /> EPA/Otha <br /> J. Additional Descriptions for Materials Listed Above �n//��,Q T/�. f y K. Handling Codes for Wastes Listed Above, <br /> 15. Spoc;al Handling Instructions and Additional Information <br /> Ny <br /> 16. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <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 /> It 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 have <br /> determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to <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 edort to minimize my waste generation and select the best waste management method that is alvei able to me and that I can afford. <br /> Punted/Typed Name / Sign re Month Day Year <br /> / <br /> 160 <br /> Ia. Transporter 1 Acknowledgement of Receipt of......... <br /> R <br /> A Pri /Typed Name Signet Month Day Year <br /> N <br /> S <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> O <br /> R <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> 19. Discrepancy Indic.:.'ion Space <br /> F <br /> A <br /> C <br /> 1 20. Facility Owner or Operatornificahon f receipt of hanrdoua materials covered by this manila exc ed In Item 18. <br /> V Prime D9d'Name Slgnaltwe Month Dsy Year <br /> DHS 8022 A(van ,,,.. UCTI NS ON THE BACK <br /> EPA 6700-22 Whde: TSDF SE ' „ua COPY TO DOHS N 30 D YS <br /> (Rev.9-98) Previous editions are obsolete. To: Ker. 3000, SGvotneMo, CA 95812 <br /> IN CASE OF AN EMERGENCY OR SPILL, CALL. THE NATIONAL RESPONSE CENTER 1-800-424-8802'. WITHIN CALIFORNIA CALL 1-800-852-7550 <br />