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Slate of Califorma—#lealth and Welfare Agency Department of Health Sarvi ion <br /> Form Approved OMB No.2050-0039(Expires 9-30-8a) Toxic Substances Control Division <br /> Sacramento,Celifomik <br /> rint or type. (Form designed for use on elite 'Ich f ewr/ter. <br /> t neralor's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS Document No. of is not required by Federal law. <br /> WASTE MANIFEST �',' - S ! -A ' <br /> 3 enefator's/Name and ailing Address _ A. St. <br /> Manib^t Document Number <br /> �� r, . <, <br /> a .•` I„�/I„.. �• <br /> "/it-�J�� B.(S�(Ueqq Genantor'a ID <br /> 4. Can eralor'sPhone(._1 �) �� - J C 7 <br /> 5 Tr s o-far 1/Company Name 6. US EPA ID Number C. State Terrific is ID C <br /> ,o p / I1. r,- D. Transporter a Phon �' ..ary f^(✓ <br /> vi 7 Transporter 2 Company Name It. US EPA ID Number E. Stale Tranaponer'a <br /> ID <br /> .f I I <br /> I., f. �/ F, Transporter',Phon ° <br /> 9 Designated Facility IN 9 and Site Address _ 10. �$EPA ID Number D. State Facility's ID <br /> T 1 <br /> u , , ry H. F & <br /> Z L 12. Containers 13. Total ie. I. <br /> t I. US DOT Description(including roper Shipping . ,and ID Number) Quantity Unit Waste No. <br /> � dPShinNameHazard ClaesNo. Type Wt/Vo <br /> J <br /> a &at <br /> U / <br /> z G a�r/„-{ I / t/(, v 6G , illy 14L !:G L iC <br /> EPA/Other <br /> ~ N •1 / i71 <br /> state <br /> E b. <br /> m A EPA/Other <br /> m T <br /> O c. stale <br /> R <br /> o EPA/Olhar <br /> m <br /> ¢ d Stets <br /> w <br /> w EPA/Other <br /> U <br /> a' K. Handling Codes for Wastes Listed Above <br /> U) J. Additional Descriptions for Materials Listed Above <br /> Z a. D. <br /> O <br /> a <br /> C. d. <br /> a <br /> z <br /> 0 15. Special Handling Instructions and Additional Information <br /> Z <br /> 2 <br /> H <br /> J <br /> ae. <br /> U GENERATOR'S CERTIFICATION: I hereby declare That the contents of this consignment are lolly 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 /> 0 <br /> international and national government regulations. <br /> N II I am a large quantity generator,I cefllty that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have <br /> ¢ <br /> columned to be economically practicable and that I have selected the practicable method of treatment, storage, of disposal currently available to <br /> O 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 best waste management method that is available to me and that I can afford. <br /> U <br /> Z Printpa Name <br /> Signature A Month Day Year <br /> r) 712ZI hl W-1 <br /> ed ` - ,'/ /' <br /> U., T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> A Panted/ e�Nam / Signature /.' Month DayL YYr <br /> N <br /> u- <br /> $ <br /> O , I8. Transporter 2 Acknowledg fief of Receipt of Materials <br /> w Month Day Year <br /> R Printed/Typed Name Signature <br /> U 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 Certification of reasipl of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature MMfh Day Year <br /> DHS 8022 A 0/87) INSTRUCTIONS ON THE BACK <br /> EPA 8700-22 YELLOW: GENERATOR RETAINS <br /> (Rev.9-88) Previous editions are obsolete. <br />