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Stale of California--Health and Welfare Agency Department of Health Services <br /> Form Approved OMB No.2050-0039(Expires 9.30 Toxic Substances Control Division <br /> Please rint ort e. (Form designed lar use an elif 'fch typewriter). Sacramento, California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Paget Information in the shaded areas <br /> WASTE MANIFEST p 0 (1, Da'2 C., t N <br /> c of is not required by Federal law. <br /> 3. Generator's Name and Maili Address A, State Manifest Document Number <br /> 8702302-2 <br /> 25 0 LA 0,,l 16 A 1n • B. State Generator's ID <br /> 4. Generator's Phone(� '� '- 3 <br /> 1,91 <br /> 0 5. nsgart r t m Coy ame r S. US EPA ID Number C.'State Transports s ID <br /> to 1�1 ``� h, ��t 0 tz� 1QZ 2 $ _ D. Transporter Phone - `A <br /> N 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> 0 <br /> m <br /> 0 Y 1 1 1 1 1 1 1 1 1 1 1 F..Transporter's Phone <br /> 0 <br /> 9. ignated Facility Name and ite-fddiess 10. US EPA ID Number G. State Facility's ID <br /> It rZ Lr <br /> 3\Z� 5 x,11,06 Z p �{-, H. Facility's Phone <br /> Q oxi a �V+d ( t C � d 3 1 807- '5:n- <br /> Z 12, Containers 13. Total 14, t. <br /> 0 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. I Type WI/Vol <br /> d <br /> " <br /> stel <br /> a C��r � r W�la� H��,nu p�i(ks �t[„{✓( /� { � a-�Z�. <br /> F N s <br /> r �! `-8Cj l <br /> �} V EPA/Other <br /> 3: E b. State <br /> CV R <br /> co A EPA/Other <br /> Co T <br /> Q O <br /> R G. State <br /> 0 <br /> 0 EPA1 Other <br /> !r d. - a State <br /> LU <br /> F <br /> Z EPA/Other <br /> NCn s <br /> J. Additional Descriptions for Materials Listed Above C � K. Handling Codes for Wastes listed Above <br /> Z JOl.LIf1 wtlti., a. b. <br /> CDd ��CCA.��1.-: <br /> w c. d.. <br /> C¢ <br /> �Z <br /> �Q 15. Special Handling Instructions and Additional Information <br /> 2 r <br /> H <br /> J <br /> J 16. ' <br /> U GENERATOR'S CERTIFICATION: t 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 /> internationaF and national government regulations. <br /> U) It 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 /> Ccdetermined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to <br /> 0 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 /> Z. Printed/Typed Name Signature t -/ , Month Day Year <br /> LIJ <br /> LL4 <br /> 2 T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> LU RMonth Day Year <br /> Z A Printed/Typed Name Si�natore <br /> Q S �! ft/ �.]Z �' � k [J <br /> LL <br /> © 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> LuR Printed/Typed Name Signature Month Day Year <br /> U <br /> E <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 PrintedlTyped�N3lpe Signature f M th Day Year <br /> �{ {�� { i3 <br /> DHS 8022 A(1187) / INSTRUCTIONS ON THE BACK <br /> EPA 8700-22 Yellow: TSDF SENDS THIS COPY TaGENERATOR WITHIN 30 DAYS <br /> (Rev.9-85) Previous editi>-tete. <br /> r <br />