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State.ol California—Health and Welfare An....cy Department of Health SnMces <br /> �orm Approved OMB No.2050-0039 930 • Toxic Substances Control Division <br /> Poe as rint or type Form designed!w use on eli - itch I evirder. Sacramento,Call/orm?. <br /> UNIFORM HAZARDOUS i Generator's US EPA ID No. Manileat 2. Paget Information In the shadfid.aroa9 <br /> WASTE MANIFEST 6 Document N1 pf Y ederatlaw. <br /> is not required b F <br /> 3.An too <br /> N/me epi MShcng A dress A. State Manifest Document Number <br /> H �ItP� fe7 /D��iy� tooQrnc 1'y3/^ 879 i 8 <br /> /� w l I mar 1.A B. State Genaret <br /> 4. Generator's Phone iJ <br /> ) 76— &�� q 3 <br /> rr <br /> n <br /> 5. T ansporter I mpany ems 6. US EPA ID Number C. Slate Transporters, <br /> .� M D. TnnapoAers Phos �—� <br /> 1. T ansporter 2 Comp ny Name r 8. US EPA ID Number E. Stale TransporteYa IS <br /> ' Q 6 F. TransportsYe Piro <br /> J 9 Designated Facility Namely°Site Address 10 US EP ID Number G. State Facility's ro <br /> Aenno Ze lr)w <br /> ? H. F ollity'8 hate 'by <br /> r 12. Contalne 13. To191 14 �•:al. <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Ousetlly Unh l Mast►NO <br /> No. Type Wt/Vo 1+ <br /> st <br /> G a w of �M6vS c!6/e Li��r�/ e <br /> - E �A/ ,oingr <br /> N <br /> V E b. Slaty. <br /> o A <br /> T <br /> O <br /> -r R <br /> h }v a 1r:v . <br /> .i d. <br /> L p: <br /> i Q1L►� <br /> iI <br /> j <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wn N Listed Above;a. <br /> b.' } <br /> r, <br /> s, of Y> <br /> .P r <br /> 15. Special Handling Instructions and Additional Information <br /> Z <br /> u <br /> T 18. <br /> GENERATOR'S CERTIFICATION: I 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 /> i <br /> international and national government regulations. <br /> If I 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 /> me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator, 1 have made a good <br /> faith effort to minimize my waste generetion and select the best waste management method that is available to me and that I can afford. J <br /> ' PrinteOyTypq Name Signature Month Day Year <br /> D <br /> 'j T 17. Transporter 1 Acknowledgeraet of Receipt of Materials <br /> R <br /> r A Printed/ yp d Name Signature Month Day Year <br /> N <br /> Le. <br /> 9 / <br /> P <br /> O la. Transporter 2 Acknowledg4mont of Receipt of Materials <br /> 1 <br /> t R Printed/Typed Nam. Signature Month Day Year <br /> E <br /> L_ <br /> 19, Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19, <br /> VPrinted/Typed Name Signature Month Day Year <br /> AIS 8022 A(1/87) White: TSDF SFNDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> PAithwi 2a INSTRUCTIONS ON THE RICK <br /> (Rev.9 e6) Previous editions are obsolete. To: P.O. Box 3000, Sacramento, CA 95812 <br /> s� <br />