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!irate of California—Health and Welfare Agency `/ <br />Please print or type, (Form designed for use on Wife (12-pllch) typewriter,) <br />.� Depeftmenl of Health Services <br />Toxic Substances Control Division <br />Sacramento C III I <br />48022 A(11/85) YELLOW GENERATOR RETAINS <br />'A 8700-22) <br />t� <br />UNIFORM HAZARDOUS a era�nr S Pf l oy G Manifest <br />~ <br />�rmj"�Nq <br />, a orn a <br />2, Page 1 Information In the shaded areas <br />la <br />WASTE MANIFEST 1 / / <br />not required by Fedarel <br />of <br />J. (yn✓�/9 Namt and MtIJ�Ro Address <br />I <br />Iw. <br />,lata anllaat� ument umbat, "�..;. <br />r\ � <br />86 453 <br />_t y : <' ,.r � _ <br />4. <br />41a Mere! e D •.. <br />Generator's Phone( <br />517ansporter 1 C=Perry Name 8. US EPA ID Number <br />C. State Tfansportees ,111 <br />r� <br />Transporter's Pho <br />7. Transporter 2 Company Name B. US EPA IDNmber <br />E. Buts Treneportsfa 1 3' <br />F. Transporter's Phone <br />B. �Qsslgnsted Fwl)Ity Name and Site Address 10. US EPA ID Number <br />, State FaollllyY ID <br />. <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Contelners <br />Total <br />Unit <br />I' <br />No. <br />Type <br />Ouantlty <br />WWoI <br />Waste No. <br />E <br />N <br />a <br />(711 <br />9i <br />A <br />b. <br />T <br />e <br />a <br />C. <br />d. <br />J. Additional, Destalptlons for Materials Listed id Atgvi'y a // K Handling Codes for Wastes Listed Above <br />A.;: /hT jr1TP,' t+ l. <br />f ' <br />15. Special Handling Instructions and Additional Information <br />j, <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully end accurately described above by <br />Proper shipping name and are classified, pecked, 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 3002(b) of RCRA, I also certify that I have a program In place to reduce the <br />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 />minihn Is the present and future threat to human health <br />and the environment. <br />PrinedlTypetl Name Signature <br />' <br />I" Month Day Year <br />TT 17. Transporter 1 Acknowledgement of Receipt of Materials - <br />Prin(adlTyped Naprb SlpnalG <br />/Month Day Year <br />4 18. Transporter 2 Acknowledgement of Receipt of Meterlals <br />f Printsdl I yPtW Name Signature Month Day.> <br />19. Discrepancy Indlcatlon Space <br />.4 <br />©\S <br />20. Faclllty Owner or ODeratoc Certlllcallon of receipt of hazardous materials covered by this manifest except as noted In Ile <br />j PrintedlTypeO Name <br />( Signature mOr <br />r <br />48022 A(11/85) YELLOW GENERATOR RETAINS <br />'A 8700-22) <br />t� <br />