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State of California—Health and Welfare Agency Department of Health Service; <br /> Form Approved OMB No.2050--0039(Expires 9-3 Toxic Substances Control Divisior <br /> Please print or type. (Form designed for use on eli._ f2- itch t ewriter). 6 Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No, Manifest 2. Page t I Information in the Shaded areas <br /> WASTE MANIFEST _ __Document No. of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> 711 S.San Jaurr=Lin street-stcc ktcn f z--lifaznia 95203 B. State Generator's 10 <br /> 4. a terator's Phone( 209 456-5788 <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's 10 e7 e, PIC <br /> .�'_L'�IQTT7 E1'V'I=4Zqr_7j1 ICiAID19131018 18 14 48P D. Transporter's Phone r rr <br /> 7. Transporter 2 Company Name 8- US EPA ID Number E. State Transporter's ID <br /> 66 <br /> F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> icksm Inc. <br /> 55 Parr Het H. Facility's Phone <br /> -=rza,Califarnia 94801 1 CAD 10 10 19 4 16 li6 415-235-1393 <br /> 12. Containers 13. Total 14. I. <br /> 11. OS DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. Type Wtivol <br /> a. <br /> State <br /> G 6 �TLTILDIY SMRA M " � ^ <br /> E T_ EPA/04fiei <br /> N lr�T..7C P,- , �JT,b `�D ?��� h T."j G 15 31 0 P Tion <br /> E b, State <br /> R <br /> A — <br /> t T EPA/Other <br /> l RO C. <br /> State <br /> EPA/Other <br /> d. <br /> State <br /> EPA/Other <br /> 1. <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> a. b. <br /> D= LEADED GASOLINU, Tom{ #1300 <br /> ICED WITH 150 LBS DRY ICE C. d. <br /> G <br /> 15. Special Handling Instructions and Additional Information <br /> t <br /> I " <br /> 16. <br /> GENERATOR'S CERTIFICATION: f 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 /> internaiionat and national government regulations. <br /> IfI 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 /> I 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 /> fai!h effort to minimize my waste generation and select the best waste management method !hat is available to me and that I can afford. <br /> Printed/Typed NameSignature y Month Day Year <br /> < ZI <br /> 1 T <br /> R 17, Transporter 1°AcknowledgerAent of Receipt of Materials <br /> A Prim Typed Name Signatur /J Month day Year <br /> N .Lc' <br /> Q18- Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed ed Name <br /> T YP Signature Month Day Year <br /> E <br /> I <br /> 19. Discrepancy indication Space <br /> A <br /> G <br /> I 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 /> Y <br /> DHS 8022 A(1/87) Blue: GENERATOR SENDS THIS COPY TO DOH5 WITH9N 30 DAYS INSTRUCTIONS ON THE BACK <br /> EPA 8700-22 <br /> (Rev. 9-86) Previous editions are obsolete. To: P.O. ?-OX 4CO, Sacramento, CA 95E02 <br /> IN CASE OF AN EMERGENCY OR SPILL, CALL THE NATIONAL RESPONSE CENTER 1-8C0-424-8802; WITHIN CALIFORNIA CALL 1-800-852-7550 <br />