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• Statq of Calitornia—Health and Welfare Agency Department of Health Services <br /> Form Approved OMB No.2050-0039(Expires 9-30- Toxic Substances mento,Control Division <br /> Sacramento,California <br /> Please riot or a. (Form desi ned for use on eli 'fch ewrifer. <br /> UNIFORM HAZARDOUS Generator,us EPA ID No. Manifa 2. Page t Information in the shaded areas <br /> D umenl o of is not required by Federal law. <br /> WASTE MANIFEST d <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> swb lee/111 <br /> / / (✓ /�{, L SCU/rl.7 `!/. B. State Generator's ID <br /> 4. Generator's Phone <br /> p Transporter 1 Cympany Anne e. US EPA ID Number C. State Transporter-s ID Q <br /> h " ,/n. iIDIniz loll D. Tra usporter's Phone _ <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. Stale Transporter's ID <br /> m F- Trensporter's Phone <br /> 0 <br /> m 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> 21-r KFacility's Phone <br /> 17 <br /> T' ;/ o &S E 3.7-•7�'�'/3 <br /> Z - 12. ontainers13. Total 14. 1. <br /> ¢ Quantity Unit Waste No. <br /> 0 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) <br /> LL �7, p No. Type Wt/Vo <br /> a.T� / t/r^P.� State z <br /> _U /'�' tJ C/ f� <br /> Z E G Irr D ( w EPA/Other <br /> ¢ U /Q IMV b <br /> N <br /> 3 E b. State <br /> R <br /> mA EPA/Other <br /> m T <br /> a O c / State _ <br /> V R <br /> mEPA/Other <br /> M d s� <br /> State <br /> 1– <br /> z EPA/Other <br /> w / A <br /> U ! <br /> � <br /> y J.Additional ascriptions for Materials Listed Above K- Handling Codes for Wastes Listed Above <br /> Z0 a. b. <br /> Q g. <br /> C. d. <br /> Na <br /> C)2: <br /> O 15. Special Handling Instructions and Additional Information <br /> Q <br /> S <br /> r <br /> J <br /> J 6. <br /> V GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully 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 /> international and national government regulations. <br /> W If I 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 /> ¢ determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to <br /> O me which minimizes the present and future threat to human health and the environment: OR, if 1 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 /> WPrinted/Typed Name Signature /.. T Month Day Year <br /> w <br /> 2 T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> w R <br /> Z <br /> A Printed/Typed Name ignature i \` Month Day Year <br /> a N A n, <br /> LL <br /> O PO 18. Transporter 2 Acknowledgement of Receipt of Materials � <br /> U1 R Printed/Typed Name <br /> Sig lure Month Day Year <br /> n T <br /> I U I <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 /> I I I I I I <br /> DNS 8022 A(1/87) YELLOW: GENERATOR RETAINS INSTRUCTIONS ON THE BACK <br /> EPA9-86)22 <br /> (Rev.9-88) Previous editions areabsolete. <br />