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State of California—Health and Welfare Agency Toxic 8uba4anc4le Dumrol Dlvlaloe <br /> Form Approved OMB No.2050-0039(Expires 930-98) S"areantg.cal9omis <br /> 7T,an.,.rt.1 <br /> e. Form desi ned for use on elite 12G en rifer. i,. <br /> FORM HAZAanifest 2. <br /> RDOUS Generator's USI 10 No. Documen-ist No. �� ! 1010(Ig�I1gG } <br /> °f la nal f04111f 1 <br /> ASTE MANIFEST A. BlsteMappeat <br /> rotor's Nem�jand Mallailp Address <br /> lL"rator's Phone9. U3 EPA ID Number C. State f }rep der 1 C.ompa y Name D. TIMe era Po porter 2 Company NameID Number E. 8Lb Tf(lneppA}('nated Facility Namee d Site AAddress 10. ID umber AMU �,n <br /> r1 <br /> 12. Containers 13. Tot I te. <br /> i Hazard Class,and ID Number) Quantity Unit ,S <br /> I I. US DOT Description(Including Proper Shipping Name, No. Type Wt/V <br /> i( <br /> i <br /> a r� <br /> ' WUS {t oil C, , b s4t61e Lt��rJ <br /> G <br /> E <br /> N <br /> E If. 1 <br /> R <br /> I A <br /> T ti <br /> 'r R a <br /> 1 r. <br /> ? <br /> d. <br /> y <br /> J. Additional Descriptions for Materiels Listed Above K HttIJQINI �+ <br /> =n <br /> 15. Special Handling Instructions and Additional Informationk,rpi-; it i 1, <br /> e <br /> u � f <br /> = 8 ' ; <br /> � rt. <br /> J 16. <br /> GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above ftransport bhihwlow <br /> rd prng 19' <br /> end are in all respects in proper condition or ranpy ga <br /> name and are classified, packed, may ecgoldinp Ip <br /> rked, end labeled, .. <br /> international end national government regulations. <br /> ? 0. <br /> If I am a large quantity generator, I certify that I have a program in place 10 reduce the volume end toxicity of waste generated Ig Iha dagrgll Y� 1 f <br /> s determined to be economically practicable end that I have aelecled the practicable method of treatment, storage. or disposal currently W410010 tg <br /> if I am a small quantity generator, I have ma 0 <br /> O me which minimizes the present and future threat to human health end the environment; OR, q Y g �,�p <br /> > lailh effort to minimize my waste generation and select the best waste management method that is available to me and that I can elford nY,wl <br /> UNtNIN.j TW9ignatur - <br /> Printed p Name y <br /> U <br /> w <br /> Ile" <br /> 17. raneporler 1 Acknowledgem N of Receipt of Materials <br /> w RMonth <br /> Z Yttetf <br /> tl'A Printed)Ty ed ems Si9nalura tI'1 <br /> a N f <br /> S <br /> U P 16. Tranap der 2 Acknowledgemenj eceipt of Materials <br /> K2;7 <br /> w O Signe is MM(fl.1P . . Yltar <br /> m R Punted/Typed Name •l,' <br /> a T <br /> U E <br /> Z <br /> 19. Discrepancy Indi etio Space <br /> 1yf 1 <br /> C <br /> I 20. Facility Owner or Operator Codification of receipt of hazardous materials covered by this manifest except as noted in gem 19. mom., Yfaf 'FI <br /> T Printed/Typed Name Signature ce '. <br /> Y <br /> h°t <br /> DHS 8022 A(1/87) Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS INSTRUCTIONS ON THE q�CK g r <br /> EPA 6700-22 t '� r. <br /> (Rev.9-89) Previous editions are obsolete. To: P.O. Box 400, Sacramento, CA 95802 qr•l+ fv fp I <br /> n h <br />