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State of Celile(nia--Health and Welfare Age ec9yID-30-88) 30 BS) <br />Form Approved OMB No. 2050---0039 (Exp <br />Pleas® ,int of I e. Form desi ned for use on efife <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />3. Ggnsgrator's Name and 11)lineddr,7 <br />�- Generawe �•� <br />5. Tr.aa�+nnsp''orter t /C_ompany_Name <br />7. Transporter 2 company N e <br />g, Designated <br />�F^aci�lityy Name and Site Address <br />j ,J <br />EP <br />6, <br />Manifest <br />Toxic auaeW-1— • <br />Sacramento. Calif <br />2. Page 1 Information in 1he shaded areas <br />o1 is not required by Federal law, <br />slate Manifest Docu��mennt�t Number <br />1 <br />State Generator's 10 <br />US EPA ID umber C. State Tren orter'a ID <br />D. Traneporte ne t <br />E. State Transporter's ID <br />F. TrenspoAer's Phone <br />G, State Facility's ID <br />10 US EPA ID Number <br />ir- <br />in Name, Hazard Class, <br />and 1D Number) <br />11. Us DOT Description (Including Proper shipping <br />E <br />12. C <br />No <br />N <br />E b. <br />R <br />A <br />Y <br />0 C <br />R <br />d. r <br />y <br />J- Additional as for Materials l`stAbove <br />F 7 <br />1 - Special Handling Instructions and Additional Information <br />Waste No - <br />i <br />EPA! Other <br />Stale <br />EPA 'Other <br />State <br />EPA/Other <br />K. Handling Cbdes for Wastes Listed Above <br />a. <br />;tely proper sni .ng <br />1t3 applicable <br />ccurL <br />name anGENERAare CERTIFICATION: packed, <br />hereby <br />and llabe ed, the <br />dcaree in all tres1pect'ssinn proper a condition for tfanspoWby highway to app <br />name and are classified, <br />internatiorril and national government regulations. <br />1f I am a large quantity generator, l certify that I have a program in place to reduce the volume and toxicity storage. wase g enspos l currentlyave a e a gond <br />detewhich minim zes the prehod of Ife <br />rmined to be economocrilly practic and ble thnd that reat #o to <br />lhuman health and #hehave selected the rentuironm nt icable tOR t I am to small quaty g disposal currently available d <br />me <br />faith effort to minimize my ante generation and select the best waste management me <br />that is available to me and that I can afford.year <br />f r r I Month Day <br />i Sii7nfiurf l . — --. wk 7r O i <br />T t7. Transporter 1 c n dgement of eceipt of �llatenals Month Day Year <br />rA <br />Signature r <br />Printed/Typed Name (l 18. Transporter 2 Ackn w e g me t f Receipt of Materials Monfh Dey Year <br />Signature <br />R Printed/Typed Name <br />T <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19, Month Day Year <br />T Signature <br />Printed/Typed Name <br />Y <br />r I n c cr r 4' _tYr r','".� 1`rli ,l:'2 DAYS INSTRUCTIONS ON THE BACK <br />DHS 8022 A U f 87) F„ur, GEN' -'R ,,A 10R )'v H'. <br />EPA 8700-22 70: P.0 <br />(Rev. 9-66) Previous editions are obsolete. <br />SPILL, C:ALI T11E NATIONAI, RESPONSF CENTER 1.800-424.8802: WITHIN CALIFORNIA CALL 1-800-855 7550 <br />IN CASE OF AN EMERGENCY OR <br />H, acility' <br />Phone <br />iners <br />13. Total 14- <br />-Quantity Unit <br />Type <br />W U V <br />Waste No - <br />i <br />EPA! Other <br />Stale <br />EPA 'Other <br />State <br />EPA/Other <br />K. Handling Cbdes for Wastes Listed Above <br />a. <br />;tely proper sni .ng <br />1t3 applicable <br />ccurL <br />name anGENERAare CERTIFICATION: packed, <br />hereby <br />and llabe ed, the <br />dcaree in all tres1pect'ssinn proper a condition for tfanspoWby highway to app <br />name and are classified, <br />internatiorril and national government regulations. <br />1f I am a large quantity generator, l certify that I have a program in place to reduce the volume and toxicity storage. wase g enspos l currentlyave a e a gond <br />detewhich minim zes the prehod of Ife <br />rmined to be economocrilly practic and ble thnd that reat #o to <br />lhuman health and #hehave selected the rentuironm nt icable tOR t I am to small quaty g disposal currently available d <br />me <br />faith effort to minimize my ante generation and select the best waste management me <br />that is available to me and that I can afford.year <br />f r r I Month Day <br />i Sii7nfiurf l . — --. wk 7r O i <br />T t7. Transporter 1 c n dgement of eceipt of �llatenals Month Day Year <br />rA <br />Signature r <br />Printed/Typed Name (l 18. Transporter 2 Ackn w e g me t f Receipt of Materials Monfh Dey Year <br />Signature <br />R Printed/Typed Name <br />T <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19, Month Day Year <br />T Signature <br />Printed/Typed Name <br />Y <br />r I n c cr r 4' _tYr r','".� 1`rli ,l:'2 DAYS INSTRUCTIONS ON THE BACK <br />DHS 8022 A U f 87) F„ur, GEN' -'R ,,A 10R )'v H'. <br />EPA 8700-22 70: P.0 <br />(Rev. 9-66) Previous editions are obsolete. <br />SPILL, C:ALI T11E NATIONAI, RESPONSF CENTER 1.800-424.8802: WITHIN CALIFORNIA CALL 1-800-855 7550 <br />IN CASE OF AN EMERGENCY OR <br />