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State of C^riifornia--Heaith and Welfare Agency Depurtment of Health Service <br /> Sorm Approved OMB No.2050039(Expires 9-30-91) Toxic Substances Control Divisit. <br /> Please print or type. (Form designed for use an Wile(124a typewriter). Sacramento,Caliiorm <br /> UNIFORM HAZARDOUS I. ator's US EPA ID No. Manifest -. ege 1 Information in the shaded areas <br /> WASTE MANIFEST C Document Na. <br /> of is not required by Federal law. <br /> 3. nerator's,N/ayme and Mailing Address A. Stats Mani s1 u an+� 'u b <br /> 4c, /Z I B. State Generator's ID <br /> 41 <br /> 4. Generator's Phone( , y ) L <br /> 5. Tr PT 1 Compo ame 1I e. US EPA ID Number C. State Transporter's ID <br /> t' r,. ( r1 t D. Transporter's Phone C11 7 <br /> NLC <br /> u7 7. fransporter 2 Co any Name 8. US EPA ID Number E. State Transporter's ID <br /> m <br /> F. Transporter's Phone <br /> ap f 9 eaignated(Facility Name•and Site Address / 10. [ US/EPA Number G. State Facility's ID <br /> Gr .� <br /> 0""7 <br /> JLr`e !J ..J Ls. F'i I r,/( - <br /> a <br /> CJ �i / H. Fapility'a Phone d <br /> • Q 'i _ "3' <br /> (AD <br /> /� 12. Containers 13. Tot I 14. I. <br /> wLL <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> ♦AM, zi ! /9 f /�� No. Type Wt/Vol <br /> C31 T G e. Woo, <br /> U S Stets <br /> C•�r� EPA/Other <br /> N :] <br /> im E b. <br /> R Stale <br /> O A <br /> Go <br /> T EPA/Other <br /> N O <br /> R c' State <br /> EPA/Other <br /> Cc <br /> F <br /> d' State <br /> Z <br /> w <br /> U <br /> EPA/Other <br /> w <br /> J. Additional Descriptions for Materials Listed Above <br /> Z K. Handling Codes for Wastes Listed Above <br /> a. b. <br /> rn � <br /> w <br /> it <br /> � � r <br /> C. d. <br /> Z <br /> z <br /> 0 <br /> 1- 15. Special Handling Instructions and Additional Information <br /> Z <br /> w <br /> J <br /> J <br /> a to. <br /> U <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J and are classified,packed,marked,)and labeled,and are in all respect&in proper condition for transport by highway according to applicable international and <br /> ELnational government regulations. <br /> cc It I am a large quantity generator,1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree t have determined <br /> O to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> } presets and future threat to human health and the environment;OR,if i am a small quantity generator,I have made a good faith effort to minimize my waste <br /> CJ generation and select the beat waste management method that is available to me and that 1 can afford. <br /> Z <br /> LLI Printed)Typed Name r}. Signature j Month Day Year <br /> ' w T 17. Transporter 1 Acknowledgement of Receipt of Materiels <br /> Z R <br /> A <br /> 1 d N Prince p d Name <br /> Si ore ) Month Day Year <br /> LL <br /> � '� <br /> O <br /> W O �18 Transporter 2 Acknowledge mento Receipt of Materials <br /> U R Printed/Typed Name Signature Month Day Year <br /> i E <br /> Z <br /> 19. Discrepancy Indication Space <br /> F e <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Cenificatio p of hazardous materials covered by is manifest except as oted in Item 19. <br /> T <br /> y Printed]Typed Na ignat <br /> L� �Z a� (�, I ri (Sir <br /> DHS 8022 A(1/88) Do Not Write Belo This Line <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DA <br />