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Depadmenl of Health Service. <br /> of CeNfomta—vteallh anO Welfare Agency Ly 3y ` Toxic Sub}kanc+s thin?Division <br /> APProvaQ OMB Noy2050-0038(Expires 930.88) ll.,� - Sap(eq' d Celibrnia <br /> seas and or 1 e. Form rlesi nod/or use on elite 12- ifc wdfar. - <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Page I Information in the shadoalea3 <br /> o um nt n <br /> WASTE MANIFEST i °I �i is not doquired by Fede <br /> j 3. Generelo's N me antl Meiling Address A. State Manifest Document Numberof'sNPopm^- I0N co = 8 7 5 7.9 0 6KCL $ I,AZPc B. State Generator's 10 _.• H <br /> - s1. Generator's Phone( �) C6. Transporter I Company Name 6. US EPA ID NumberC. State Transporter's IDeV`C41�,O `` TR0rKiNG (A1C' , r D. Tranaporteia Phone7. Transporter 2 Company Name vI\ V /�eB. US EPA ID Number E. State Transporter'.WF. Transporter's Phone9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's IDBLODr H. F7111 y's Ph rteRtCk4 moND/ CA q 1 D q b (03 5 235 —139 <br /> 12. Containers 13. Total 14. 1. <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> qqpp 77�� �—yy� 7� T�-(�{� /'r No. Type Wt/Vo <br /> e.�tF�le e—:Mpr / �1 ✓f�,�l7G I/ "moi Stete .� 1 <br /> N CA1.1 Mp.N I A RE60L ATDO W (+s M ON 2 En1LlIV 1� <br /> State <br /> E b. <br /> R <br /> A EPA/Other <br /> T <br /> O c State <br /> 7— <br /> R <br /> EPA/Other <br /> d Stale <br /> EPA/Other <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> �mPry �Ac,�,�lnl� N�,#� , (I �D ►vl� 01 <br /> b. <br /> 20 lbs or- t>Py I E�MPTy G-ASC>L I Ne -0� p d. <br /> 634 , tcc-D Lu iT}i 20 405 br- D" Lee r <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,1 certify that 1 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 1 am a small 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 /> Pri ed/Typed Nama / Signature Month Day Year <br /> 01 <br /> R 17- Transporter 1 Acknowledgement of Receipt of Materials <br /> A Printed/Typed Name _ Signature Month Day Year <br /> P 18 Transporter 2 Acknowledgement of Receipt of leriels <br /> O <br /> R Printed/Typed Name Signature Month Day Year <br /> T <br /> E <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> L <br /> 1 20. Facility Owner or Operator Codification of receipt of hazardous materials covered by thIlest except as noted in Item <br /> T Prints /Typed Name Signature onfh Day Year <br /> Z 1 /i <br /> DHS 8022 A(1187) - 1 TRU ONS ON THE BACK <br /> EPA 8700-22 <br /> (Rev.9-86) Previous editiona are obsolete. <br /> IN CASE OF AN EMERGENCY OR SPILL, CALL THE NATIONAL RESPONSE CENTER 1-800-424-8802; WITHIN CALIFORNIA CALL 1-800852-7550 <br />