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e of California—Health and Welfare Agency /,� Department of Health Services <br /> m Approved OMB No.2050-0039(Expires 930- ./ / J Toxic Substances Control Division <br /> ease print or type. (Form designed/or use on eli -pitch typewriter). Sacramento,California <br /> UNIFORM HAZARDOUS Generators US EPA ID No. Mment No.Manifest 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST101,61v /f D 11 ocuof is not required by Federal law. <br /> 3. Generator's Name and Mailing Address - A. State Manifest Document Number <br /> 88461898 <br /> B. State Generator's ID <br /> 4 Generator's Phone <br /> h 5. Tr nsporter 1 Company Name 8. US EPA ID Nu C. State Transports r's <br /> m r <br /> n D. Transponer's Phone j <br /> N <br /> m 7. Transporter 2 Company Name 8. S EPA ID u be t E. State Trensporter's ID <br /> m <br /> O F. Transporter's Phone <br /> 0 <br /> m <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> rajt 1 H Facility's Phone <br /> 4 <br /> M ¢ 1 12. Containers 13. Toter 14. I. <br /> yy Ij 11. US DOT Description(including Proper Shipping LL p ( g p ppin Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> J No. I Type Wt/vol <br /> a. Lli .' ?t- `., °~( ri t t.: `!''a r.:'C.. i-"7,.t ICS States` <br /> Z G <br /> E _ EPA/Other <br /> M E b. Stets <br /> C0 N R <br /> A <br /> m T EPA/Other <br /> V o <br /> a R c. State <br /> 0 <br /> 0 <br /> m EPA/Other <br /> Ju d. State <br /> Z <br /> W <br /> O EPA/Other <br /> W <br /> W J. Additional Descriptions for Materials/Listed Above a. Handling Codes for Wastes Listed Above <br /> W "` ' � 1- +.:( �'=e ;. 1; -!t OKI .. .. �. . of f d .., a: / b. <br /> rT-s <br /> a <br /> Z <br /> 0 <br /> 1- 15. Special Handling Instructions and Additional Information <br /> a <br /> Z <br /> i <br /> f. <br /> J <br /> J <br /> O 18. <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 respects in proper condition for transport by highway according to applicable international and <br /> a national government regulations. <br /> m <br /> If I am a large quantity generator,I certify that I have program in place to reduce the volume and toxicity of waste generated to the degree have determined <br /> 0 <br /> 0 be economically practicable and that have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> present and future threat to human health and the environment:OR,if I am a smell quantity generator, have made a good faith effort to minimize my waste <br /> V generation and select the best waste management method that is available to me and that I can atf tl. <br /> WPrinted/Typed Name .� - Signature { Month Day Year <br /> W _. L.� .� 1... L.4 ) <br /> IILI T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Z R <br /> a A Printed/Typed Name Signature Month Day Year <br /> N (� <br /> W S `�.. G r l f m l:: <br /> W O 1 ranaparter 2 Acknowledgement of Receipt of Materiels <br /> UT Printed/Typed Name Signature Month Day Year <br /> E <br /> Z_ <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 exc as noted'n Item 19. <br /> T <br /> y Printed/Typed Name Signature Month OF Yell <br /> r�t.�•�r �.... �1L.K <br /> DHS 8022 A(1/88) Do Not Write B ow Thi 4ne <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. <br /> • Yellow SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />