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State of California—Health and Welfare Agency Toxic Substances Control Division <br /> Form Approved OMB No.2050-0039(Expires 9-30-911 Sacramento,Celifornii <br /> Please print or type. (Form designed for use on alit ottch typewriter). <br /> UNIFORM HAZARDOUS enerator a US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> Document No. <br /> WASTE MANIFEST of in not required by Federal law. <br /> 3. Generator's Name and Melling Address A. State Manifest Document Number <br /> CARL MVMA 8 <br /> 1100 W. 11th Street B. State Generator's ID <br /> Tracx, CA 95304 <br /> e. Gener M'sPhone(209)836-0005 <br /> 5. Transporter 1 Company Name e. US EPA 10 Number C. State Transporter's ID <br /> 001757 <br /> w 111161 fl D. Transport 'a Phone <br /> n <br /> m 7. Transporter 2 Company Name S. U9 EPA ID Number E. State Transporter ID <br /> (101 sqg <br /> S Tom's C r re l n ({ F. Transporter's Phone 223-5012 <br /> Go 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> H 8 H Ship Service Oonpany <br /> t� 220 China W- sin Street H. Facility's Phone <br /> San Francisco, CA 94107 ICIAIDIOIO14171711 1 6 8 (415) 543-4835 <br /> O <br /> 12. Cont more 13. Total 16. 1. <br /> LL Quantity Unit <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class.and ID Number) nWaste No. <br /> No. Type Wtit <br /> J <br /> t U a' State <br /> 7 3 241 <br /> E RAZkl as ( WASTE LI QUIJ, N.O.S. ORVrE NA 9189 G EPA/Other <br /> 0 � <br /> 3 0101 E b. 1 TIT <br /> state <br /> a R <br /> A EPA/Other <br /> m T <br /> a R c. State <br /> g EPA/Other <br /> w itState <br /> H <br /> ZENVIRONMENTAL HEALTH EPA/Other <br /> U <br /> W <br /> W J. Additional Descriptions for Materiels Listed Above K. Handling Codes for Weates Listed Above <br /> 0 e. b. <br /> Q. CASOLINE, U1 A Z WATEK 01 <br /> W <br /> tl <br /> cc c. . <br /> J <br /> Z <br /> r 16. Special Handling Instructions and Additional Information <br /> Z <br /> APPROPRIATL PRJrXTIVE CWMI% AID RESPIRATOR. <br /> J <br /> V 18. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J <br /> 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 /> a national government regulations. <br /> K If I am a large quantity generator.I certify that I have a program in place to reduce the volume end toxicity of waste generated to the degree I have determined <br /> 0 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 am a small quantity generator.I have made a good faith effort to minimize my waste <br /> 0 generation and select the bast waste management method that is available to me and that I can afford. <br /> ZSignature Month Day Year <br /> W Printed/Typed Name / <br /> L�� '�9--L11 101014 1819 <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Z RMonth Day Year <br /> < A Printed/Typed Name Signature <br /> IL o NS CL"ELAI D VALREY <br /> P 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> W R Printed/Typed Name Signa r Month Day Year <br /> Z E J(JAL J. CUITrAW am 11 1010141819 <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in hem 19. <br /> Y Printed/Typed Name Signature Month Day Year <br /> DHS 8022 A(1/88) Do Not Write &low This Line <br /> EPA 8700-22 Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (Rev.9-88)Previous editions are obsolete. , <br /> To: P.O. Box 400, Sacramento, CA 95812-0400 <br />