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Slate of Celifornla—} alth and Welfare Agency ` Department of Health Services <br /> B Y <br /> Farm Approved OM6 N F rm des 039(Expires 8 31 8) Toxic Subalancai Control Division <br /> Pinase print or type. (Form des nod for use nn 01?. I➢rch ry ,, rots) Sects sato,California <br /> I I JNIFORM-i4AZARDOUS' 1 1. Generatora.US EPA ID No._ .Merril_.., ..2..Page t <br /> Doc lent No. Information in the shaded areas <br /> WASTE MANIFEST17I °I I �s not required 6y Federal law- <br /> 3 Generators Name and Meiling Address r• 1 �. '9 _ A State Manifest Uocumoet Number <br /> a <1 6 f � � 8 Stare penaretor a IC <br /> 6- Generators Phcne <br /> 0 5. Transporter 1 Company Name `B. US EPA 10 Number - C, State Transporter a IQ <br /> h <br /> Trenapoders Phon�il <br /> W ]. Tran poncr 2 Company Name B US EPA IU Number <br /> E: State Transportsr.e ID <br /> 7ren6Pd11a1-a Phone: <Y ., <br /> m e. Oos gratod FaciliTyrName and Site Address y � 10. US EPA ID Number G grata Fembfy a ID <br /> .l♦� <br /> d' ) _1 <br /> Fee <br /> q f <br /> U H Facility A Phone <br /> ..-- <br /> 12. Containers '3. Total m 1. <br /> f <br /> O L US DOT Description(Includinn V -t a Vpin-. Nort o.Hazard Glass,and ID Number) Quantity Unh Waste No. <br /> No. 1 TYpe _ Wt/go <br /> a. 'Ah �. ,;AI Y <br /> E l I It � . <br /> 3 N ,'i'f <br /> N iE b. <br /> R Slate <br /> 00o� <br /> rp. T - EPA/Other <br /> N <br /> State <br /> EPA/Other <br /> ¢ d. <br /> _ I n e) �r State <br /> Z <br /> Li <br /> J. ATd,t nn I De srriptir iof fella 91a0 ,r r,. J -,--iI K }lantlling Cndoa for.Wastes listed Above <br /> .Z 1 4, e <br /> ti kj f <br /> CC <br /> 1 15 Spa,lel Handling Instructions and Addrtlonsl Inlormatlon <br /> J 16. <br /> ci <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this eonalgi meat are fully and accurately described above by proper shipping <br /> dams and are classified, packed, marked, and labeled, and aro in all respects In proper condition,for transport by highway according to applicable <br /> inte,nahonal and national government regulations. <br /> If I em a lago quantity genera•or,I certifv that rise. a m^s em In ntva tr �.+ - a"e' t Iave <br /> s I ;elermined to be economically practicable and that I nave selected the practicable melho; 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 I am a small quantity gene.alor, I have made a good <br /> T faith effort to minimize my waste genelabon and select the best waste manaoement method that Is available to and that I can afford. <br /> Printed/Typed Name Signature % Month Day Year <br /> w <br /> h� / ) <br /> zs R 17. Trnspoder i Acknowledgement of Receipt of Materiels <br /> u ! __ <br /> A Printed Typed Name Signature Month Day Year <br /> F8. n a <br /> Trapudnr 2 Acknowlodgomont of Receipt of Mri <br /> ateels <br /> q o T ed/Typed Name SlguetureMonth Day Year <br /> z' 18. Discrepancy Indication Space' <br /> A <br /> C <br /> I <br /> 1 20. Facility Owner or Operator.Certification of receipt of hazardcus materials covered by thAmanlfest except as noted In Item 19. <br /> T I r r 1d1/Ty edName Signature t^" _ Month Day Y9an <br /> DHS 6022 A T/8])EPA 870o 22 t( GREEN HAULER RETAINS. ,) `INSTRUCTIONS ON THE BACK <br /> (Rev.9-6fi) Previcue editions are obsolete. <br />