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Stet of GMomia--Health efM WeMara Agency Depanmem of Health Se-ices <br /> Form Approf Cavetl OMB No.eat h and W 039(Expires 9-3P Toxic Substances Control U���sion <br /> a Please print ort e. (Form deal ned!or use on ellf itch typewriter). Sacramento. CafJomie <br /> UNIFORM HAZARDOUS Generators US EPA ID No. Manifes 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST G _ 'r 7 ,_,rc l ant N of <br /> is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> Hr ✓6LF-/AJ tk)C 87LJ23034 <br /> / .3 C� .' <br /> !��^.//(t J)At 'Y 1- 7 J B. State Generatoes ID ♦♦. ♦ <br /> 4 "ib <br /> 0 <br /> S. Transporter 1 Company Name 6. US EPA ID Number C. State Trensporter's <br /> D. Transporter'.Phan. r,{�. <br /> m 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID - <br /> m <br /> 8 R Trensportar's Phone <br /> C? 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> v <br /> U 1 X71/ r H. Facility's Phone - <br /> a rA F'F e' ' �f f..!7 ,.e{; ,1 ) i. -T <br /> ! <br /> Z 12. Containers 13- Total 14. I. <br /> ¢ Quantity Unit Waste No. <br /> O 11. US DOT Description(including Proper Shipping Name,Hazard Claes,and ID Number) <br /> UL - No. Type t/Vo <br /> State <br /> - <br /> = G <br /> � N `/ EPA/Other <br /> u -;�_ f' ' l4 ',Y%Il'," !/r. /rJT Vr {i,' =' ,n J :�A. <br /> 3 E b. State <br /> N R <br /> A EPA/Other <br /> m T <br /> d O <br /> e R a'f l State <br /> m It�l) Irti n .,f�/j0 EPA/Other <br /> State <br /> Z ���,�.�i L/V`� <br /> U U EPA/Other <br /> / /- CXx✓"- <br /> M� J. nal Descri t- ns aerials Listed Above i K. Handling Codes for Wastes Listed Above <br /> Z a- b. <br /> �O <br /> w <br /> MQ C. d. <br /> NQ <br /> ' pZ <br /> I`O 15. Special Handling Instructions and Additional Information <br /> ryH <br /> W Z <br /> ¢ <br /> 1 ~ <br /> J <br /> J 8. <br /> U GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> t name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> international and national government regulations. <br /> a If 1 am a large quantity generator. I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have <br /> m <br /> ¢ determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available <br /> O me which minimizes the present and future threat to human health and the environment; OR, it I am a small quantity generator. I have made a good <br /> 1 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 /> 2 w Printed/Typed Name _ Signature Month Day Year <br /> w <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> W <br /> w R <br /> Z A Printed/Typed Name Signature i� Month Day Year <br /> N <br /> 1 O Q 1s. Transporter 2 Acknowledgement of Receipt of Materials - - <br /> tu R Printed/Typed Name Signature Month Day Year <br /> T <br /> U <br /> = 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name - Signature Month Day Year <br /> DHS 8022 A(t/87) YELLOW: GENERATOR RETAINS INSTRUCTIONS ON THE BACK <br /> EPA 8700-22 <br /> (Rev.9-86) Previous editions are obsolete. 40 <br />