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State of California-Health and Welfare Agency Department of Health Services <br /> Form Approved OMS No.2050--0039(Expires 9-30- Toxic Substances Control Division <br /> Please rint ort e. (Rarm designed far use on ef/fe itch ewrffer). • Sacramento.California <br /> UNIFORM HAZARDOUS 11. Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST IC A L O U Documan�No. of is not required by Federal law. <br /> 3. Generator's Name and Mail Address ,a / L A. StateManifestDocc�um�elnt]Nurm�ber <br /> Z l U 1 . 1 Q A 11 1 S. State Generatdre m . <br /> 4. Generator's Phone(201 _ 5, to <br /> p 5. Transporter 1 Company Name 8.^ US EPA ID Number y C. State Trensporte'a ID <br /> uz f V/�r� Q• \ Z U D. Transporter's Phone 9-514-2\(V) <br /> 0 7. Transporter 2 Company Name 1 8. US EPA ID Number E. State Transporter's ID <br /> CP <br /> ' $ F. Transporter's Phone <br /> m 9. Designated Facility Name and Site Address �- t 10. US EPA ID Number G. State Fecilit ' I <br /> GilS50wd� � Q4'Z'trJ4rt _- � �� <br /> 31-1 'g"y\jpiA Z4 H. Facility's Phone <br /> Z12. Containers 13. Total 14. L <br /> O11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Ouentity Unit Waste No. <br /> LL 1,o. Type Wt/Vo <br /> a <br /> G . to C f ` C3 \ State <br /> Z 22 <br /> ? I \� EPA/Other <br /> I= N 1, 5 <br /> 3 E b. State <br /> N R <br /> m A EPA/Other <br /> m T <br /> RC. State <br /> d <br /> C? EPA/Other <br /> W d. State <br /> f <br /> 1Zyf - EPA/Other <br /> Nw J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> m <br /> a <br /> m <br /> M¢ '.i9iElNLVINE" a' d <br /> C\IQ :craft +: <br /> Oz <br /> 0 15. Special Handling Instructions and Additional Information L <br /> Q <br /> 1- <br /> J <br /> Q 8r <br /> U 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 /> LL <br /> m 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 in be economically pard future <br /> and that I have selected the practicable method of treatment, storage, or disposal currently available to <br /> d <br /> U me which minimizes the present and tutors 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 /> U <br /> Printed/Typed Name Year <br /> J,pT Signature /' r , Month Dey <br /> 131 <br /> w T <br /> 17. Transporter 1 Acknowledgement of Receipt o Materiels <br /> w R <br /> Z A Printed/Typed Name Signature�y�-L pEgp� Signature ^ Month Day Year <br /> N ML IAI IIJES � l <br /> LL <br /> O PO /8. Transporter 2 Acknowledgement of Receipt of Materials <br /> Printed/ y`ped`Nam�al}7�71y Sig tures Month Day Year <br /> U <br /> .E 19-,Discrepancy Indication Space <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 /> i y Printed/Typed Na Signature Month Day Year <br /> CL rl c I IIE- 1 I / FiS <br /> DHA 8022 A(1/e7) Yellow: TSDF SENDS THIS COPY T ENERATOR WITHIN 30 DAYS INSTRUCTIONS ON T BACK <br /> EPA 8700-22 <br /> (Rev.9-86) Previous editions are obsolete. <br /> It <br /> Y <br />