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stare Of Ualtmrnia—Heellh and Welfare Agency <br />Farm Q)roved OMB No. 205G--0039 (Expires 9.2 1 <br />of.... <br />Department of Health Serve <br />Toxic Substances Control Divii, <br />DHS 8022 A (1/87) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />EPA 8700-22 <br />(Rev. 9-88) Previous editions are obsolete. To: P.O. BOX 3000, Socromeri CA 95812 <br />INSTRUCTIONS ON THE BACK <br />UNIFORM HAZARDOUS <br />1.Generatw'sUSEPA toNo. Manifest <br />Sacramento, Cello, <br />2. Paget <br />WASTE MANIFEST <br />Document No. <br />Information in the shaded areas <br />of <br />Is not required by Federal law. <br />3. ngrglw's N a an ailing A rasa <br />IIS ' ���eum i�o��x Jv <br />A. Slate Manifest Document Number <br />- <br />, <br />Fir) <br />�+ 0'3..,qB. <br />4. Genaratw'e Phone ( ) / mQr ii <br />State Genaratw'e ID <br />5. Tr apo r I C7.pany N e a. US EPA ID Number <br />C. State Treneportar's ID <br />y <br />D. Traneporter's Phone <br />z0 <br />]. Transponer Company ame 8. US EPA b Number <br />E. Stale Transporter's I <br />F. Tianeporter'a Phon <br />- <br />9. esign ed F cigty No 'a and Address 10. yyS EPA ID umber <br />�e enn� e/ <br />- <br />G. State Facility's 10 <br />uvn 21DOO fil d <br />( <br />,y1 <br />-H <br />H. ility s Phone <br />_ <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13Dblal <br />Quantity <br />le. <br />Unit <br />I. <br />Waste <br />No. Type <br />Wt/Vp <br />No. <br />G <br />/ <br />e �tlS'(Go7r M4o5�b1@ <br />stem <br />E <br />EPA/Other <br />N <br />4" 444if4:20 <br />I fil <br />R <br />b. <br />State <br />I A <br />EPA/Other <br />T <br />� O <br />R <br />o' <br />state <br />EPA/OPW <br />d. <br />8mN <br />EPA/(#ler <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />a. <br />b. <br />c. <br />d. <br />15. Special Handling Instructions and Additional Information <br />16. 1 <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 />If 1 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 smell quantity generator, I have made a good <br />faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. <br />Printetl/T ed Nama <br />Signature Mwrth Day Year <br />R <br />17. Transporter 1 Acknoviledgelfhent of Receipt of Materials <br />A <br />Printed/T lame <br />Signature P. Month Day Year <br />N <br />oWd <br />S <br />0 <br />18. Transporter 2 Acknowledge of Receipt of Materials <br />OL <br />R <br />Printed/Typed Name <br />Signature IF Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manitest except as noted in Item 19 <br />T <br />Y <br />Printed/Typed Name <br />Signature Month Day Year <br />DHS 8022 A (1/87) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />EPA 8700-22 <br />(Rev. 9-88) Previous editions are obsolete. To: P.O. BOX 3000, Socromeri CA 95812 <br />INSTRUCTIONS ON THE BACK <br />