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tri'/tsW,4 uaz3(,-/a4S"z_7 r4, <br />0 v � �• <br />StmekfvCall forria— Health and Welfare Agenco <br />' CII t r t (form desl ned for use on elite (12 -pitch) typewriter.) <br />m <br />CD <br />N <br />N <br />N <br />CII' <br />CO <br />Department of Health Services <br />Toxic Substances Control Division <br />Sacramento, California <br />ease <br />n o pr ype. g <br />UNIFORM HAZARDOUS <br />1. Generator's US EPA I D No. Manliest <br />2. Pepe 1 <br />Information In u the shaded areas <br />law.not required by Federal <br />WASTE MANIFEST <br />(.Q 1 % 1 r ' i T �Dop 1 kkNgo. <br />// <br />I of / <br />3. Generator's Name and Melling Address / <br />Lod,' V,',-, /vr$T"r,c <br />A. State Manifest Document Number <br />86272283 <br />FY s-c4ovl <br />g/ 5 U/� s 5/,A. `/ s `/ <br />B. State Generator's iD <br />4. Generator's Phone ( �: G9) �C r� ���/ <br />f <br />�/¢%a� �•i�t^ r 7 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID <br />.(,. <br />UR1✓ <br />Nrt�r i Cr.N �. Vr r;; nr e..n >r'C. "'`�'r.Tr' !"��'F'.r! C. / 1M Ml 3 <br />D. Trensporter's Phone I- 614W <br />' <br />7. Transporter 2 Company Name 6. US EPA ID Number <br />E. State Transporter's ID <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Adgregs ig. US EPA ID Number <br />(.'o.� <br />G. State Facility's ID -. <br />f�iw...,-•fr,., E,.,✓•rros,....,...-/c./,f/1�%r.,�,�.-.y�..�' <br />C`,�f>1�Gc' 'y�.�3 <br />//Y5-5—(--li /, &LF� <br />H. Facility's Phone <br />/HC /+' Cf�rtiGr/L.XCiv 70IC /15?r�/ Il 3 <br />f1y�— <br />12. Containers <br />13.Total <br />14 <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />No. Type <br />Quantity <br />Unit <br />WtNol <br />Waste No. <br />G <br />a. <br />E <br />d. <br />J. Additional Descriptions for Materials. Listed Above ���,6 <br />K. Handling Codes for Wastes Listed Above <br />`�I-r4 <br />ail" <br />15. Special Handling Instructions and Additional Information <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by <br />proper shipping name and are classified, packed, marked, and labeled, and are In all respects In proper condition for transport by highway <br />according to applicable International and national government regulations. <br />Unless I am a small quantity generator who has been exempted by statute or regulation from the duty to make a waste minimization certification <br />under Section 3002(b) of RCRA, I also certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I <br />have determined to be economically practicable and I have selected the method of treatment, storage, or disposal currently available to me which <br />minimizes the present and future threat to human health and the environment. <br />Printed/Typed Name <br />Signature - Month Day Year <br />T <br />17.Transporter 1 Acknowledgement of Receipt of Materials <br />P/IntedlTyped Name J; % <br />Signa e i �' -. Month Day Year <br />P <br />0 <br />16. Transporter 2 Acknowledgement of Receipt of Materials <br />RMonth <br />T <br />Printed/Typed Name <br />Signature DayYear <br />E <br />R <br />19, Discrepancy Indication Space <br />F <br />A <br />c <br />I <br />L <br />T <br />20. Facility Owner or Operator. Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />IF <br />Printed/Typed Name <br />Signature Month Day Year <br />DHS 8022 A (11185) <br />(EPA 8700-22) <br />YELLOW: GENERATOR RETAINS <br />