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Stale of&&Iifomla—Health and Welfare Agency <br />Fortr.Approved OMB No. 2050--0039 (Expires 9.30.88) <br />Department of Health Services <br />�./ Toxic Substances Control Division <br />Sacramento, California <br />MS 8022 A (1/87) <br />:PA $700-22 YELLOW: GENERATOR RETAINS <br />'Rev. 9.88) Previous editions are obsolete. <br />INSTRUCTIONS ON THE BACK <br />F. <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest <br />Document No. <br />2. Paget <br />- toformation In the'shaded areas <br />L <br />' WASTE MANIFEST C G Fi % 5' 2 <br />of <br />isnot required'by Federal law. <br />3. G orator's Name and Meiling Address [j <br />A��i") T -Z., lr.71 pi4ri}t' jC/; <br />A. State Manifest Document Number <br />� <br />B. State Generator's ID <br />i <br />4. Generator's Phone aiq) 576 - <br />7 <br />S. Tr►nspo/{tar 1 om! ny Name a, US EPA ID Number <br />Yet <br />/ �r� A)�EGr.ri l 4 (, (j "% •, / <br />C. State Transporter's ID <br />D. Transporter'e Phon <br />7. Transporter 2 Company Name e. '' US EPA ID Number <br />E. State 'Transportar'e ,a <br />F. Transporter'► Phone <br />9. Designated Facility Name and Bila Address 10. US EPA ID Number <br />A (l <br />4/L/r!rpy 61 <br />G. Slate Facility's ID <br />04, /, fI(,_ �.(-(-& <br />4,10 l(.(i/1 <br />H. Facility's Phone.. -. <br />-1/-A 7-(-A 'KI c )1-3 6-j <br />-) tc� :? 7- /,-y <br />/-*? <br />r 1. <br />I I . <br />12. ConlainerV <br />f3. Total <br />14.I. <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity <br />Unit <br />Waste No. <br />No. Typo <br />Wt/vo <br />a. J <br />State <br />211 <br />G <br />4,3 <br />EP /Otho <br />N <br />e%'1 A/1 11 % <br />fJ <br />j E <br />b. <br />State <br />R <br />A <br />EPA/Other <br />T <br />R <br />c. <br />State <br />EPA/Other <br />d. <br />State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />C. <br />d. <br />- <br />15. Special Handling Instructions and Additional Information <br />18. <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 />II 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 small quantity generator. I have made a good <br />faith effort to minimize my waste generation and select the beat waste management method that is available to me and that t can afford. <br />Prinle /T ped Name <br />Signature" / Month Day Year <br />R <br />17. Transporter I Acknowledgement of Receipt of Materials <br />A <br />Printed/Typ dNema <br />Signature / Month Day Yeer <br />IV <br />pfa. <br />Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Prinled/Typed Name <br />Signature Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in item 19. <br />T <br />y <br />Printed/Typed Name <br />Signature Month Day Yeer <br />MS 8022 A (1/87) <br />:PA $700-22 YELLOW: GENERATOR RETAINS <br />'Rev. 9.88) Previous editions are obsolete. <br />INSTRUCTIONS ON THE BACK <br />F. <br />