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State of Callfomla—Health and Welfare Agency ,g See Instructions on Back of Page 6 Departm.nt o!Health Servicos <br /> Form Approved OMB No.2050039(Expires 9 30 9`1 Toxic Substances Control Division <br /> Pleaeg print or type. Form designed for use on eLt itch typewriter). and Front Of Sacramento California <br /> 4 <br /> UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest 2. Page t Information In the shaded areas <br /> WASTE MANIFEST Document No. <br /> 0 r of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address z �,_, A. State Manifest Document Number N <br /> CL.LOVli r, r <br /> &-:9 N. S1emigiii. ) <br /> R. State Generator's ID <br /> 4. Generator's Phone( , ) 04 ":.:'{t'''�'1$ CLI. <br /> a r �_r r <br /> 5. Transporter 1 Company Name e. US EPA ID Number C. State Trenaponer:'s ID <br /> N t - fF t:✓ C ` Q, Q .i D.Transporter's Phonal <br /> '0 7. Transporter 2 Company Name 8. US EPA ID Number E State Transporter's ID <br /> ,+m <br /> 3 c TL�p'nf f, rt DT F 11(C,l p "e R t h F; Trenepgrter'a Phoner)r. -tti _FF <br /> 9. Designated Facility Name and Site Address 10. US EPA to Number` G. State Facility's ID <br /> J <br /> a 13E Hik,S$i_ COAT"ANY 7 : <br /> O i T : H. Facility's Phone <br /> . <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) 12Containers 13. TotalQuantity Unit Waafe No. <br /> No. Type Wt/Vol <br /> E E C:ALIFOR141A ON ,Y i EGUL2'il'ED I <br /> N <br /> E b. .. <br /> ti <br /> St <br /> R ets <br /> o A <br /> b T <br /> EPA/Other <br /> K O <br /> y <br /> v R o <br /> State <br /> n <br /> EPA/Other <br /> ¢ d <br /> L <br /> Z <br /> State <br /> Z <br /> w <br /> J EPA/Other <br /> w <br /> m J. Additional Descriptions for Materiels Listed Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> d e: In. <br /> -' - <br /> w 07; i104 <br /> s S[>ECiELC GRAV I'i Y' .0. <br /> C. d. <br /> a , <br /> z <br /> 0 <br /> 1- 15. Special Handling Instructions and Additional Information <br /> 2 <br /> 2 <br /> X i,Ik 8TR!AL PUPLf'ED INTO 'CAN& CAR CF FOR still'lt1UN, <br /> ',<> Ftrvtrt -:pt�)1,}'';'ccy r� 't'•' �t3 if ' - : . - , , it ( 'H : StifiSE%. COF`it`ANY } <br /> V 16. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> 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 /> N <br /> quantity generate,,canary feet I have a program in place to reduce the volume and toxicity of waste generated to the degree 1 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 /> } present 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 /> O generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> wPrinted/Typed Neme Signature <br /> 0 Month Day Year <br /> W <br /> w T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Z R <br /> A Printed/Typed Name <br /> ¢ N .,.`_ _. Signature ! Month Day Year <br /> IS <br /> -11 <br /> WO 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> ¢ RPrinted/Typed Neme <br /> O TE Signature AW.Inth Day You, <br /> 2 <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 except as noted in Item 19. <br /> T <br /> y Printed/Typed Name Signature Month Day Yeer <br /> i <br /> 't)HS 8022 A Do Not Write Below This Line ' <br /> :.PA 8700-22 <br /> (Rev.6-89)Previous edition.are obsolete. ` <br /> YELLOW: GENERATOR RETAINS <br /> i <br />