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.. xpires nt of Health Services <br /> Please rint or ty2e. Form designed for use on elite12- itch t ewrifer. ��` Toxic Substances Control Divieior <br /> Sacramento,Celifomie <br /> UNIFORM HAZARDOUS Generator's US EPA ID No. Intormatlon in the shaded areae <br /> Manife 2. Pape 1 <br /> WASTE, MANIFEST f, oc a <br /> °} Is not required by Federal law. <br /> 3. Generator a Nems and Meiling Address A. State Document Numb <br /> Mandest er <br /> 5nu t�I r1 t nz.l r,G � FZttn, s TA nw 6z . <br /> 876 <br /> �A /, r�v 1� f J B. State Generator s ID <br /> 21043 <br /> 4. Gee erator'shone f 4,r . <br /> 5. Transporter 1 Company Name e. /'U;S EPA ID Number C. State Trenaparter'e ID Z , <br /> rC (C L�/G�l1 A-I �"� T&D L - �] `7 l Z. �L' D. Transporter'a Phone �I .O <br /> 7. Transporter 2 Company Neme B. US EPA-f0 Number E. State Traneporter'e ID <br /> F. Transporter's Phone <br /> a��K �olyls <br /> 9. Designated Facility Name end Site Address 10. US EPA ID Number G. State Facility's ID <br /> , l.1c <br /> t'A- r H. Facility's Ph, <br /> l fCr1 mw a101A 00 S 3 3 <br /> 71. US DOT Description(Including Proper Shipping 12. Containers 13. Total 14. ' I, <br /> p pping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> t �J �},�! 7�,.. �� (` No. Type Wt/Vo <br /> G a. NA5: € E i'O P1 7 C;110Fr GU jzl J'6� State r <br /> N h.�+r rzwi�. kh Gc +4)K%J�) toftSTY a WLIV EPA/ t5 <br /> E b. Y7�.} <br /> R - State <br /> A <br /> T <br /> O EPA/Other <br /> r <br /> R <br /> C. <br /> - EPA/Other <br /> e. <br /> State <br /> j EPA/Other <br /> J. Additional Descriptions for Materials Listed Above - K. Handling Codes for Wastes Listed Above <br /> i+'fiY C' Ui,I t-.� . Q k, Gf2 Co ia. b. <br /> w�1�r Gabs. • . O y ! c f d. <br /> 15. Special Handling Instructions and Additional Information <br /> n <br /> 16. <br /> GENERATOR'S CERTIFICATION: 1 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 govemment regulations. <br /> If I am a large quantity generator,I certify that 1 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 /> 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 Al Signatur <br /> nth Day Year <br /> F <br /> T <br /> it. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Printed/Typed Name 1 Signatur , <br /> SJ c--Q.�� �UZ i f Month Day Year <br /> Is ..� <br /> 0 18o Transporter 2 Acknowledgement of Receipt of Materials I _ <br /> R Printed/Typed Name Signature E g t ( Month Day Year <br /> 19. Discrepancy Indication Space - �•/ <br /> F <br /> A <br /> C <br /> L - -*q.• - <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except ae noted in Item 19. <br /> T Printed/Typed Name - <br /> Y Signature <br /> Month Day Year <br /> DHS 8022 A(1/87) I I I I _ <br /> EPA 8700-22 YELLOW: GENERATOR RETAINS INSTRUCTIONS ON THE BACK <br /> (Rev.9-86) Previous editions are obsolete. <br /> IN CASE OF AN EMERGENCY OR SPILL, CALL THE NATIONAL RESPONSE CENTER 1-800-424-8802; WITHIN CALIFORNIA CALL 1-800-852-7550 <br />