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Stats of California--Health and Welfare Agency \ - Department of Health Services <br /> / Form Approved OMB No.2050-0039(Expires 9-3Q \ Toxic Substances Control Division <br /> Pleaae rint or e. (Form designed Or use on:11,11 tch typewriter). Sacramento,California <br /> UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> Document No. of is not required by Federal law. <br /> WASTE MANIFEST d <br /> 3. Generator's Name and Mailing Address -� `n f A. State Manifest Document Number <br /> e( t 8�.71`.pNW y ZV i. �x LI�Ut"I I l' A�, T• E. State Generator's ID <br /> 4. Generator's Phone(Zl„J y <br /> p 5. T sparter 1 Comyany Name 6. US EPA ID Number C. State Transporters ID <br /> 989 33-7 <br /> W rU a ` <br /> 1fuM IL1N {„) V D. Trenaporter's Phone <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transpoder's ID <br /> m <br /> F. TranaDorter's Phone <br /> m 9. Designated Facility Name and Site Address f0. US EPA 10 Number G. Sta a Fa ' <br /> G1ITsa—a � � ,N��y <br /> .. V 3 •� t s}p,lvta PH. Facility's Phone <br /> 05-!12 <br /> Z¢ ' 12. Containers 13. Total /14. <br /> LL 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt/Vo <br /> State <br /> G Z2 <br /> i <br /> F N tUt • " L4-L OIL <br /> �• EPA/Other <br /> 3: E b. lJ V V State <br /> R <br /> o A r \i EPA/Other <br /> Co T NIIN�� <br /> F C. 'i fSCAL state <br /> o EPA/Omer <br /> m <br /> cc d State <br /> Z <br /> m EPA/Other <br /> U <br /> oto J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wsales Listed Above <br /> NZ - a. / b. <br /> �d <br /> m <br /> C. d. <br /> fY7w <br /> CVQ <br /> ipZ <br /> O 15, Special Handling Instructions and Additional Information <br /> opZG 1�u4 S \� \iii, <br /> w LX I <br /> J <br /> J 8 <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 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 /> = Printed/Typed Name Signature _ - r r Month Day Year <br /> W �• <br /> � ' <br /> W <br /> T•4' T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Z A Printed/Typed Name S n re <br /> Month Day Year <br /> S lv F(L. <br /> LL <br /> O 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> W R Printed/Typed Name Sig tura Month Day Year <br /> W T <br /> U <br /> E <br /> = 19.19. DiacrePn Space <br /> F ) <br /> a =• oC�� -z <br /> A <br /> C <br /> I <br /> I 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by 11-lis manifest except a noted in Item 19. <br /> T Printed/Typed Name Signelure Monrh Day Year <br /> y 5 � �� (i I 14� <br /> DHS 8022 A(1/87) Yellow: TSDF SENDS THIS COPY TO GENERATOR WIT 30 DAYS INSTRUCTIONS dN THE BACK <br /> EPA 8700-22 <br /> (Rev.9.86) Previous editions are obsolete. -• _. - _.__�+ _ - _ _. - - _„ <br /> 1 <br />