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Stale of California—Meallh and Walleye Agency Department of Health Services <br /> Form App-oved OMB No.2050-0039(Expires 9- `_/ Toxic Substances Control Division <br /> Please print or type. (Form designed for use on elite -pitch fypewr/fer). Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Page 1 Informetion in the shaded areae <br /> WASTE MANIFEST Docament No. <br /> ofJ is not requited by Federal law. <br /> 3. Generator's Name and }N Address ��/D E4S N I A. Slate Mind I Document Number <br /> IrrI S � OaQ `D(.�Y 1 1' --t aJ 8 <br /> xi R.�-+- OT�i�� ((� �r GT-GC ('ri-�'J/ �O� B. State Generator's ID <br /> 1111 <br /> A. Generators Phone(I Ll _ �;n y <br /> 0 b. Tran ortor t Company Name 6. US EPA ID Number C. State Tranaponer's ID <br /> k-<,-; ^ ( K,,,n 101( D. Trensporler's Phone <br /> Ste- <br /> m 7. Transporter 2 Company Name / / B. U5 EPA I Nu bar E. Stale Transponer's ID <br /> F. Transporter's Phone <br /> 9. Des' natal Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> (VQ EiC.�SEiJ -)C. <br /> C♦U 'S�G ✓/' ' ,is H. Facility's Phone <br /> dA <br /> O 12. Conlainers /3. Total 14 <br /> . I. <br /> r 1 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Ouantity Unit Waste No. <br /> No. I Type Wt/Vol <br /> co Stale <br /> ; G <br /> CoE ♦ EPA/0th r <br /> (Anu ' / / <br /> N r A <br /> E D. <br /> Ste e <br /> N R <br /> T7 EPA/Other <br /> ry 0 <br /> e R <br /> C. <br /> State <br /> _ EPA/Other <br /> H d. 51 ate <br /> Z <br /> W <br /> U EPA/Other <br /> w <br /> toJ. AtldBi al Detions for Materials Listed Above K. Handimp Godes for Wastes Listed Above <br /> N ��s � � IQ SFI �� r�►� �a3�y a b. <br /> reed w /6 s �r y � - C. d. <br /> Z <br /> 0 <br /> 15. Special Handling Instructions and Additional Information <br /> Z <br /> W <br /> J <br /> J <br /> U <br /> 16. <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 M proper condition for transport by highway according to applicable international and <br /> national government regulations. <br /> ¢ R I am•large quantify Venerator.I cenity that I have a program in place to reduce the volume and toxicity of waste generated to the degree 1 have delermtned <br /> O 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 end the environment;OR,if 1 em a small quantity generator.I have made a good fehh effort to minimize my waste <br /> Ly generation and select the beat waste management method that is available to me and that 1 can afford. <br /> 2 <br /> Printed/Typed Name Si esu Month Day Year <br /> ¢ L <br /> Jul <br /> WT 17. Transporter t Acknowledgement of Receipt of Materials <br /> R <br /> Q A Printed/Typed Name <br /> N /y <br /> Signature / Month Day Yeer <br /> 0 P h •✓ o 11&9L'2 <br /> W O 18. Transporter 2 cknowledpement of Receipt of Malarials <br /> N <br /> T Printed/Typed Name Sipnetura Month Day Year <br /> 0 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 Cenifinlion of receipt of hazardous materials covered by this manifest except as noted M Rem /9. <br /> T <br /> Y Printed/Typed NameSipnetura Monts Osy, Wear <br /> DNS 6022 A(1/68) Do Not Write Below 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, Socrometdo, CA 95812-0400 <br />