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I <br />ie of Callfornia---Health and Weilare Agency <br />rrm Approved OMB No. 2050 0039 (Expires 9.30 - <br />ease rint of e. Form desF ned !or use on elf + <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />3„ Gpnerator'e Name e M9�liR0�A�ddres <br />4. Ggraora Phone ` <br />6. Tr naporter Y C mp�ny N�rn��� <br />7, Transporter 2 Company Name <br />!�-'Iq <br />I_ -r Department of Hualth su,,. <br />j. `-j- �J Toxic Substances Control Divis, <br />Sacramento, CBIIIOrr <br />ch f ewrilerJ. - <br />nerator's US EPA ID Nn Manitest 2. Page Information in the shaded areas <br />10 V t ° of Is not required by Federal law. <br />A. State Manifest Document Number <br />87621371 <br />B, St le Ge arator'a ID <br />3 � <br />g, US PA ID Number C. state ran porter's ID <br />D. Transporbsor Phon f <br />®, US EPA ID umber E. State Transporter'a Ib <br />l I I I 1 1 1 1 1 F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10 US EPA ID Number <br />11. US DOT.Deacriplion (including Proper Shipping Namo, Hazard Class, and ID Number) <br />a. , , } Tial-�S <br />E <br />N <br />E Fb. <br />R <br />A <br />T <br />O <br />R c. <br />d <br />G. Stale Facllily's ID <br />H. lity' Phone <br />12, Containers 13. Total - 14. I, <br />Quantity Unit Waste No <br />No. Type wilvo <br />/1 Stale / <br />�4 'f <br />EPA /p r <br />U T State <br />EPA+Other <br />Stale <br />EPA/Othar <br />EPA/Other <br />Additional Descriptions for Materials Lisiod Above � �," �� :: Handling Cadet for Wastes Listed Above b. <br />d. <br />-- - • IF- <br />16. special Handling Instructions and Additional Information <br />"-- <br />.„r F„ _' fry-(! f/r`j'Jif/./JL�j.I <br />} <br />16. <br />GENERATOR'S CERTIFICATION: I hereby declare that She 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 />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 smatl quantity generator, I have made a good <br />faith effort to minimize my waste generation and select the best waste maI nagement method that is available to me and that I can afford, <br />— - <br />Printed/T VV-W'el fine M�� iyn:#lure Month Jay <br />r 1 e l' <br />T 17. Transporter 1 Acknowledgement of Receipt of Materials <br />RMonth .Day er <br />A Print;Name/ Signet. C <br />NS f <br />PO IB. ransporter 2 Aeknowiodgemenl of Recnipl of Malorials "" _ -_ <br />P. Signallue Month Day Yea' <br />Printed/Typed Name <br />E 4 <br />19, Discrepancy Indication Space <br />F <br />A <br />C <br />I 20. Facility Owner or Operator Certification of recoipt of hazardous malenels covered t s anitest except as Haled in item <br />Y Pri�d/Typed Name / Sipnaiure <br />+ n <br />Month Day Yee: <br />DHS 5022 A (1/87)^ l f)1t is I 7 CTIONS ON THE BACK <br />EPA 8700--22 <br />(Rev. 9.88) Previoua editions are obsolete <br />IN CASE OF AN EMERGENCY OR SPILL_ CALL THE NATIONAL fit ',;PONSE CENTER 1-800424-8802; WITHIN CALIFORNIA C.AI L I El{x7-1{r,1 r' <br />