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Statti�or t:autornla--Healtlj anC wshare Agency <br /> Department of Health Sarvlca <br /> I Toxic Substances Control Division <br /> Sacramento,Callfomis <br /> Please print or type. (Form designed for use on Mite(f 2-pitchl typewriter.) i <br /> t <br /> UNIFORM HAZARDOUS a rotor o. Manifest. '; <br /> Page Infor in e s areas <br /> WASTE MANIFEST � • �• -.�j,�.j Document No. ie not required by Federal, w <br /> law. <br /> 13. anerlSf>tor m <br /> s ae a Mailing ss <br /> o _ }- <br /> .(i. ;,iSh-�`i�}l`i •`..':���r' i.`� .:� � ;'I'• -, � Ji "�'t�Y ;,.rl I ' % : ��, <br /> ~ L: <br /> 4. Csanerator's6. US-EPA 10 <br /> {ranspo eve I Corppany Name <br /> �• •�7 +.�y{u�ym,tb'er J <br /> C-A <br /> r111ansporter ny N ame .. usNOgnsted <br /> .Jkadlity�3 �t jR he ess 10. .�.'US EPA 10 Number � <br /> 11.US DOT Description Incl �� 1 tamers 14. > <br /> p (including Proper Slti Name,Hazard Clesx and/D Nurrt6ert <br /> e r.� a �4. <br /> Total Unit �fY <br /> Tvoe Ouant[tvr <br /> Lk <br /> .4,11 �V'tiLi �1.:',tj�� ',� } <br /> It <br /> X. <br /> A b <br /> R� L <br /> '.f1 <br /> T4 L <br /> { <br /> n e contents this'. constpnmentare fully and accurately descft •; c,F� <br /> v , <br /> we by PmW shipping name and are classified,pm*od,marked,and labeled,and are In all respects in proper condition for, <br /> lei sport by s000rding W appticebis knernationel.mW national- regullak)D . <br /> Date <br /> N. j <br /> t <br /> ,4.Transporter 1 of Receipt of Materials _ �4 <br /> YPed Na 5lgna r Month Day• Ye #,1 <br /> q <br /> IS.Transporter,2 Aeknowrriedpernsrrt or Receipt of Materials' Data <br /> ., E Printed/Typed Name Signature y; r Month Day. Year s <br /> 18.Disarepar"Indication.SP <br /> Te <br /> 7 2QIlty Owner or Operator: Certification of receipt of hazardous materials covered by this maniftfst except as noted in <br /> ! Y t nt ' me Date <br /> ! nature e' ,�� f_ Manch Day Yw <br /> DHS 8022 A (7/e4) , <br /> Green: HAULER RETAINS <br /> (EPA 8700,22) <br /> IM sski <br />