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State of California --Health and Welfare Agency <br />hForm Approved OMB No. 2060-0039 (Expires 9- <br />• Ploaeo not ort e. Form designed for use on ell - itch typewriter) <br />l <br />Departmeol of Health Service <br />ToxIQ Substances Control Divlsio <br />Sacramento, Collforn, <br />III 14 8022 A ( v 87) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS INSTRUCTIONS ON 1 HE BALI% <br />I PA 8 700 - -2: <br />Iliev. 9-86) Previous editions are obsolete. To: P.O. Box 3000, Socroment0, CA 95812 <br />- UN6FORM HAZARDOUS <br />I. Oenefa'or'. U$ E PA ID No. Menllest <br />2. Paget <br />Information In the shltded areae <br />WASTE MANIFEST <br />Document No. <br />of <br />is not required by Federal law.' <br />t enr tUor Ner end Mailing Address <br />Ally fVcfry%vM 9&K /�3 <br />A 81ate Manifest Document Number <br />" 9 500.8 0 <br />Nr G� Q♦ J p <br />9. State Qenerator's ID , . <br />4. Generator's Phone )s�6�� <br />-C (-1 -' <br />5. and 1rlr y Name 8. US EPA ID Numbed <br />C. stake Transporters I . . <br />jom <br />(f w 6 7J r <br />D: Transporter's Ph <br />7 Transpurter 2 Comp Name a. US EPA ID Number <br />E. State Transporter'# <br />F. Trensporter'a Pho <br />9 osiunated Facility Nam and . e Address to. / US EPA ID Number <br />Q. State Facility's ID �) �� z {{ <br />.L._1.LL4 <br />H. 1°acility a hone <br />[ C/V ..._.. . <br />12. Contain s <br />131 Total <br />14. <br />1 <br />l 1 US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />No. I Type <br />Quantity <br />Unit <br />Wt/vo <br />Wants <br />-_�_ <br />G <br />E <br />EPA/Otho <br />N <br />E <br />b. <br />""Is <br />N <br />_ <br />EPA/Other <br />A <br />T <br />C <br />State <br />IT <br />t <br />EPA/Other <br />d <br />Stale <br />EPA/Other <br />J Additional Descriptions for Materials listed Above <br />K. Handling Codes for Wastes <br />listed Above <br />b. <br />f J�ciu{` q �a ( Rite SC Wcc rGl <br />a... <br />d. <br />16. Special Handling Instructions and Additional Information <br />fi. <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper !:hy-lml I <br />n:unr and are classified, packed, marked, and labeled, and are in all respects In proper condition for transport by highway according to apphc0,44 <br />nternational and national government regulations. <br />II I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste genarated to the degr— I h: , <br />deterrnnied to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently availrihlr• I' <br />no which minimizes the present and luture threat to human health and the environment; OR, If 1 am a small quantity generator, I have madcs a 100(0 <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 />• <br />Prime vped Name <br />/ / <br />Signature Month Uay <br />a I �i� e !e <br />t <br />1, Transporter 1 Acknowledgemient of Receipt of Materials <br />H------ <br />A <br />/T <br />Printed ped Name <br />Signature Month--i'avY'e.n, <br />I' <br />I?1. transporter 2 Acknowledgement of Receipt of Materiels <br />H <br />T <br />Printed/Typed Name <br />Signature Month Dai Year <br />F <br />It <br />A <br />19. Disc(opaacy Indication Space <br />C <br />1 <br />1 <br />20 I acilily Owner or Oporator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. 7r. . <br />Month Day I <br />I <br />tial <br />P-1-iniad/Typed Name Signature <br />Y <br />! i -_L. _ <br />III 14 8022 A ( v 87) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS INSTRUCTIONS ON 1 HE BALI% <br />I PA 8 700 - -2: <br />Iliev. 9-86) Previous editions are obsolete. To: P.O. Box 3000, Socroment0, CA 95812 <br />