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State of California—Health and Welfare Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-91) Department of HeaHh Services <br /> Please print or type. (Form designed for use on elite 1z Tbzlb 8eDelalmea Control Division <br /> ( typewriter). � <br /> UNIFORM HAZARDOUS 1 Ge rator's US EPA ID No. Manifest Page 1 <br /> WASTE MANIFEST Document No. Information in the shaded areas <br /> r (j - c of is not required by Federal law. <br /> 3. Generator's Name and Meiling Address A. State Manifest D/O�.k.ment Number <br /> B. State Generator' <br /> 0o 4, Generator's Phone( ) 1, <br /> ,p <br /> S. Transporter t CompanyName e. US EPA ID Number G State Tranaporter's ID <br /> n <br /> d D. Trensporter's Phone <br /> 7. n oder 2 Company Name- ' 8. U ECA f7um ar E. State Trensporter's I <br /> 6 <br /> oF. Transporter's Phone <br /> `Y 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> 4< .�tL*f lfiflt't(5& ^:frY'Y 11.: <br /> 3333 N. HN1.33H. a ty P on� – .. .. <br /> CA. 953o3 <br /> 2. on aineis T oto 14. I. <br /> u^ya 11. US DOT Description(Including Proper Shipping Name,Hazard Claes,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt/Vol <br /> U a. [[ <br /> ♦R?Z G L r !.K:_f , !.vr � U, p State I . <br /> VaJC <br /> r E EPA/Other <br /> N <br /> E b.� <br /> R State v <br /> m A <br /> PT <br /> N O EPA/Other <br /> a R <br /> Ito <br /> State <br /> A I n EPA/Other <br /> w d. <br /> State <br /> Z <br /> 0 ENVIRONMENTAL HEALTH EPA/Other <br /> W <br /> Z J. Additional Descnp one or aterials Listed Above K. Handling Codes for Wastes Listed Above <br /> O a. b. <br /> N <br /> W <br /> ¢ C. d. <br /> J <br /> t <br /> 15. Special Handling Instructions and Additional Information <br /> J <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 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 /> to national government regulations. <br /> ¢ If I 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 determined <br /> p 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 /> O generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> W Printed/Typed Name Signature Month Day Year <br /> W T 17. Transporter 1 Acknowledgement of Receipt of Materials ` <br /> Z R <br /> A Printed/Typed Name Signature Month Day Year <br /> N <br /> O S <br /> P <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materiels <br /> UT Printed/Typed Name Signatuall Month Day Year <br /> E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in hem 19. <br /> T <br /> y Printed/Typed Name Signature Month Day Year <br /> DNS 8022A(1/88) Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. <br /> YELLOW: GENERATOR RETAINS <br /> ' — -- - — — — — — — — — — — — — — — — — — — — — — — — — — <br />