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�.aennandWelfareAgency " a' - - ..._._ --oOMB No. 205 _ ------ <br /> I <br /> "�'�'��"�"�------ ---- <br /> 0—igne (Expires n e1i Ll Z 7 - <br /> Department of Health Services, <br /> ase int ort (Form designed for use on ell titch fvoewrite, T Toxic Substances Control Division <br /> UNIFORM HAZARDOUS Sacramento,Calilomia <br /> on etor'a US EPA ID No. Manifest <br /> WASTE MANIFEST Do m or 2. m ge/I Information in the shaded areae <br /> 3�e�qIj( qq�� e Wait ea If ! is not required by Federal law. <br /> /11ir Af F'�q`�- Q{� <br /> r 1/�5 A. Stats Manifest Oocumenl Numhar <br /> .�o b 5 Toc�To'fi o %a <br /> <. Generator'&Phone Icy S ' - B. State Generator's ID <br /> 5. Tyansporter 1 Company Nar(IB� <br /> 8. U$EPA ID Number C. State Tranaporter'e,ID <br /> L + <br /> RILKSOII ���cl��ntcr Svc t D O 4 SPhone. a c <br /> ]. Transporter 2 Company Name r D. Trenaporter's <br /> & S EPA ID Number E. State Transporter's ID <br /> 9. Designated Facility Name antl Site AddressF. TransPoner'a Phone <br /> K K� Zy <br /> S EPA Numb,,GAa t r '� ID O. Stele Facility's ID <br /> i/1(�, pVG <br /> At l.] 6!{,9cIQGI H. Facility's Phone <br /> C A 0 oq c1 6 6 9 i6- 5-/ 9;F1 t. US DOT Description(Including Proper Shipping Name,Hazard Claes,and ID Number) 12. Containers I& Total 14, <br /> 1. <br /> Quantity Unit Waste No. <br /> e_ Ak.5 TE �ff'1 No. Type Wt/Vo <br /> G �rY.Srv��acrz' /j�N� S1ate,f .4 <br /> N Rra o eva5r <br /> 3 otic y p o T <br /> EPA/Other <br /> A <br /> Slate <br /> T <br /> O <br /> R c. EPA/Other <br /> r <br /> State <br /> d. EPA/Other <br /> State <br /> J. Additional Description,for Materials Listed Above EPA/Other <br /> E� UNC ' OAT O 64118 04mi TAN K. Handling Codes for Wastes Listed Above <br /> io�c Qac, tvir,� PRy /Cra 1.17s, 01 b. <br /> C. d. <br /> Y <br /> 15. Special Handling Instruction and Additional Infsmilatlon <br /> f �ioCigjLes <br /> 15. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents or this consignment are fully and accurately described above b <br /> name antl are d national 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. Y proper shipping <br /> If 1 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 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 theyynquantity OR, if 1 am a.small generator. I have made a pcotl <br /> faith effort to minimize my waste generation and select the best waste me Sgempnt method thal4s available :me and that I can afford. <br /> Pri Ty etl and <br /> IQ� ` , VOW+'I.O VC1f <br /> Sipn <br /> 1 / Month Day Year <br /> 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Prints, e <br /> Typd Nae <br /> aa <br /> N /\ Signature <br /> P -- ' <br /> S �'7 rl V<7 1}S-s Month Day Year <br /> O 18..Transporter 2 Acknowledgement of Receipt of Mstarlets Q 8 O g g <br /> APrinted/Typed Nama <br /> E Signature <br /> Month Day Year <br /> dication Space <br /> F 19. Discrepancy In� <br /> A <br /> C <br /> I <br /> L <br /> I 20. Facility Owner or Operator Certifiealion of receipt of hazard materiels covered <br /> T Pri led/Typed anileat except as n fui in, `11 19. <br /> Y �1414NN14N pW <br /> Signature <br /> Month Day year <br /> tPA 8 8022 A(1/87) 1315 <br /> Rov9-86)-86) Previous editions are obsolete. <br /> tYellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 3 6AY 'INSTRUCTIONS ON THE BACK <br /> e _ P <br /> IN CASE OF AN ERNERGPfdt"a MC1 j1PI6L, cA <br /> pIt, iHQ NAVIONIAty NelY►fef " RYTIYk9 fsY9i/.AYA.IMMIIYI iNr{Nir alAf.lpr7pMie MALI J.uvu ass:.re.. <br />