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Stele of Csldomia-Nesllh and Welfare Agency (� 1- Department of Health Services <br /> Formdppiovad OMS.No.2050--0039(Expires 9.30.9 1) r Toxic Substances Control Division <br /> Please print or type. (Form designed for use on elite 'Ich typewriter). Sscramenlo,California <br /> UNIFORM HAZARDOUS n.Rdor's US EPA 0 No. Manifest 2. Page I Information In the shaded areas <br /> WAlit <br /> STE MANIFEST 7 e 11 j Docemeno. l <br /> of Is not required by Federal law. <br /> 3. Gener lora Name and Melling Address A. State Manllail Document Numbh <br /> 8231286 <br /> / r,, (ter S. Silva Omeralor9 ID <br /> 4. Goneraler'a Phone( / ) X17 r7? /�C/2/� (A 17 7l 1 <br /> 7v .27 I <br /> r� S. Transporter 1 Compan}'Name 8. US EPA ID Number C. State Trans <br /> p9rter'a ID <br /> 3< V / n D. Transporter'.Phone <br /> N <br /> m <br /> T. Transplorler 2 Co any Name 8. US EPA ID Number E. Slate Transporter's 1 <br /> g1 1 1 1 1 1 1 1 1F. Transporter's Phone <br /> m <br /> 9. Design ted Facility Ne and SI a Address 10. US EPA ID Number O. 91a1a Facility's ID <br /> 11Tl� � e 1 C e CU <br /> 00 0 �` <br /> U �� �/ L. (I r 1 t r,4�.{�L]S 1 b l �-/ ` N. Facility's Phone . <br /> N-z L l 'U ca 1 <br /> ¢ 12. Contslnera 13. Total 14. I. <br /> LL 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Ousnllly Unit Waaler No. <br /> M No. Type WI/Vol <br /> Nv 'W1�5 tc �11. state <br /> p <br /> 003 CzL<w�t� ll-ItTa,� � <br /> G EP /gher <br /> �; N ✓j44T 1a I4 <br /> E b. <br /> R tale' <br /> A <br /> T EPA/gher <br /> N D <br /> v R <br /> C. State <br /> EPA/Other <br /> k d• stat <br /> W <br /> U <br /> EPA/ghar <br /> W <br /> = J. Additional Descriplions for Materiels Listed Above K Handling Codes for Weals.Llelad Above <br /> LL �L'� Pt Uy�� e� �rou LA Gasdl �TesToRw�2 b. <br /> ¢ kuJ�'r�� LeSS�V�w1LOh� 9w� O`LR�IdUA � <br /> J 1111 C —� hr C. d, <br /> O I.l l `I 11,E �'A � IA t-\ V,- <br /> 0 <br /> Spacial Handling Instructions end Additional Information <br /> 2 <br /> W <br /> i-r ' <br /> I a r.. <br /> < I8. <br /> U <br /> J GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> -f and are classified,packed,marked,and labeled,and are in All respects In proper condition for transport by highway according to applicable International and <br /> 0, national government regulations. <br /> y <br /> ¢ It I em 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 1 have determined <br /> O to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> present and future threat to human health and the environment;OR,If I em a smell quantity generator have made a good faith effort to minimize my waste <br /> U generation and select the beat waste management method that Is"enable to me and that I can alto <br /> Z <br /> W <br /> Printed/Typed Name Sipnatu Month Day Year <br /> W T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Prinledl Typed Ne ma 1` S r nal re - _ <br /> LLO S I }S'4. > Month Day rYs Year <br /> P 1 <br /> W O I8. Trnnnporler 2 Acknowledgement of Receipt o1 Materiels <br /> TPrinted/yyped Name Signature Month Dry Yoe,E <br /> 2 <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I 20. Facility Owner or Operator Certllicallon of receipt of hazardous materiels covered by this manifests opt as noted In ham 19. <br /> T <br /> y PrlptaQl Typed Name Signelu '- - <br /> �(7'/j,e• Month Day Year <br /> L !/ <br /> DHs 8022 A(1188) Do Not Write Below This Line <br /> EPA 8700-22 Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (Rev.9-8e)Previous editions era obsolete. To:P.O. Boz 400,Socrnmeato, CA 95812-0400 <br />