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State of Cell fornla—Kkal th-ai d Welfare Agency 4. <br />Please print or type. (Form designed for use on ellfe (12-plich) typewriter.) <br />Department of Health Services <br />Toxic Substances Control Division <br />Sacramento, California <br />DHS 8022 A (11185) Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />(EPA 8700-22) To: P.O. Box 400, Sacramento, CA 95802 <br />UNIFORM HAZARDOUS <br />1. enerator'e US EP ID No. <br />Manifest <br />o N. <br />2, Page 1 <br />Information In the she ad areas <br />a not required by Federal <br />WASTE MANIFEST <br />% I J 7 9 <br />of <br />law. <br />3. Ge erator' Nam and Mallin Address <br />A. State Manifest Document Number <br />86314453 <br />p'[l`� <br />C19& 9�aacl <br />S. State Generator's ID <br />S <br />4. Generator's Phone <br />5. ansporter 1Name 6. US EPA ID Number(' <br />C. State Transporter's o <br />\Company <br />6 3 <br />D. Trensporter's Pho <br />7. Transporter 2 Company Name US EPA ID Number <br />E. State Transporter's <br />F. Transporter's Phone <br />91. Q�e'signated Facility Name ann_yd�Siite Address 10. US EPA ID Number <br />G. State Facility's ID <br />H. YJ oV C::1G66 <br />rf�rL c-io 732, - / f� 7 O� 6 4 " <br />12.Containerd <br />13. <br />14. <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number)I <br />Total <br />Unit <br />Waste No <br />No. Type <br />Quantity' <br />WtrJol <br />A <br />b. <br />T <br />0 <br />R <br />C. <br />d. <br />J. Additional Descriptions for Materials Listed Above, <br />K. Handling Codes for Wastes Listed Above <br />A-6y,16q.,T J,4771IA rAj V'171, llc—C�10(1 <br />15. Special Handling Instructions and Additional Information <br />� 3&)47 <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by <br />proper shipping name and are classified, packed, marked, and labeled, and are In all respects In proper condition for transport by highway <br />according to applicable International and national government regulations. <br />Unless I am a small quantity generator who has been exempted by statute or regulation from the duty to make a waste minimization certification <br />under Section 3D02(b) of RCRA, I also certify that I have a program In place to reduce the volume and toxicity of waste generated to the degree I <br />have determined to be economically practicable and I have selected the method of treatment, storage, or disposal currently available to me which <br />minimizes the present and future threat to human health and the environment. <br />PrintedlTyped Name ature Month Day Year <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materiels <br />R <br />A <br />N <br />Printed/T ped IN Sig Month Day Year <br />5 <br />P <br />0 <br />18.Transporter 2 Ackndwiedgement of Receipt of Materials <br />a <br />T <br />Printed/Typed Name <br />Signature Month Day Year <br />E <br />a <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />T <br />20. Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manlfest except as noted In Item 19. <br />v <br />Printed/Typed Name <br />Signature Month Day Yeer <br />DHS 8022 A (11185) Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />(EPA 8700-22) To: P.O. Box 400, Sacramento, CA 95802 <br />