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ute of Cellfornle—Health and Welfare Agency <br />orm Approved OMB No. 2050--0039 (Expires 9 <br />Please runt or It e. Form designed for use on <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />3'. GFt ereior's Name and Mailing Addres <br />wn`PorJ. <br />s US EPA ID No <br />uini� sm <br />��41 <br />�0 <br />4. ner <br />eF.-gT - hone l ) r <br />5. Transporter 1 Company Name n- <br />7. Trans r 2 Com Name 6. <br />C <br />9, Designated Facility Name and Site Address 10. <br />U Ipj A�� <br />USrEPA ID Number <br />US EPA ID Numbe <br />'�' ' I IL J -1I <br />LIS EPA Iii Number <br />11. US DOT Descriptlon (Including Proper Shipping Name, Hazard Class, and ID Number) <br />IWA PAeic k� <br />E I <br />N <br />E b. <br />R <br />A <br />T <br />O G <br />I R <br />Department of HealtConti S avis, <br />Toxic Substances Contra) Drvis� <br />Sacramenlo, Cahf-r <br />! 2, Page 1 information in the shaded areas <br />a1 1 15 not required by Federal law. <br />A. Slate Manliest Document Number <br />879213 <br />a. tate Gan ator'a ID <br />C. Stale Tra aporter'a 10 <br />r D. Tranaporter'e Pillion <br />E. Slate Trsneporler's 1D Cl1S)223-.5011. <br />10FTransporter's Phone <br />G. Stale Facility'a ID <br />"No.Type <br />'s Picone13. Total 1a.Quantity Unit waste No. <br />Wt1Vo <br />state <br />State <br />EPAIOther <br />State <br />d. _ <br />EPA/Other <br />I <br />r K. Handling Codes for Wastes Listed Above <br />J. Addlllonel Descriptions for Malariels Listed Above a 6. <br />` ,•;';�,3�� (.['i l"['r� E r� 1 bs rb2� pE-12 ir�x� C. d. <br />pNMI <br />1 cit <br />15. Special Ha1n�dling Instructions <br />�yand Addili%on�e'S'Information <br />,q. /''� � J ,,. ,t�y���� <br />`'[J� , V [�!� /�- y >, r rFEjo RSV I S[./i� `vim— f) 1 - <br />N a o IIfTV 5 'Tr�n dW�'Sr©/ d <br />18.ro per shipping <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by P p hcahE{, <br />name and are classified, packed, marked, -and labeled, and are in all respects in proper condition for transport by highway according to app <br />iinternational and national government regulations. <br />i. If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity o1 wasle 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 t. - <br />me which minimizes the present and future threat to human health and the. environment; OR, i1 I am a small quantity generator, I have made a gnnr! <br />faith elforl to minimize my waste generation and soled the hnsf wastp managnment method that is available l0 me and that I car afford. <br />i Prim d/Ty�d Name r Si net a Monfh Dey �1`r,r <br />Z441A <br />11J r <br />T 17f Transporter 1 Acknowledgement o1 Receipt of Materials _- <br />R <br />Month Day )'ea <br />A Printed ams Signature <br />. P 18. Transporter 2 Acknowledgement of Receipt of Materials <br />I O - <br />PrinladlTypad Name Signature Month pay Yeh, <br />E <br />19. Discrepancy Irdicalien Space <br />F <br />A <br />C <br />1 1 <br />L <br />20. Facikly Owner or Operator Cerlification of receipt of hazardous mril.+:rials covered b 1 andesl except as noted in It — <br />1 Y PrinledlT ped Name f `.�r+rratun• ATnnlh Dny Yew <br />GLvt <br />DHS 8022 A (1/87) iNS ON THE BACK <br />l EPA 8700-22 <br />(Rev. 9.86) Previous editions are obsolete. N (Q <br />IN CASE OF AN EMERGENCY OR SPILL, CALL THE NATIONAL RESPONSE CENTER 1.800.424 8802; WITHIN CALIFORNIA CAL( <br />