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-—��naiii uriu rrc+n cra hyeii�y <br />Form Approved OMB No. 2956-9039 (Expires 9-30-88) <br />please 5rini or type. Form desi ned for use an efir- (ig- itch r ewnter). <br />UNIFORM HAZARDOUS Ge erator's US EPA ID No. Mani! <br />WASTE MANIFEST q <br />a m <br />3. nerator'g�i�rng, er}�.�dail}np dd ���, J � t,� <br />9�N Li4 9db 2- <br />5. Transporter 1 Company Name 6. _ US EPA ID Nuyrrtber <br />7. Transpdrter 2 <br />8, <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />N <br />E b. <br />R <br />A <br />T <br />Q <br />R c. <br />d <br />J. Additional Descriptions for Maters Listed Above �� �� ;F�' ! � 1 <br />Toxic Sdbstances Conlral Divl511 <br />co�rnr„onrn Ca6forn <br />2• Paget Information in the shaded areas <br />of / is not required by Federal law, <br />State Manifest Document Number <br />B. State Generator's ID <br />C. State Trandporler's Io �LQC <br />D. Transporter'° Phone <br />E. State Transporter`a ID <br />F. Transporter's Phone <br />G. State Facility's ID <br />H. <br />12. Containerg <br />/ 13. Total <br />Quantity <br />14- <br />UnitWaste <br />I. <br />No. <br />No. <br />Type <br />WI/Vo <br />C M5 <br />Stale 0--2- <br />EPA/Other <br />Stara <br />EPA/Other <br />State <br />EPA/Other <br />State <br />EPA/Other <br />K. Handling <br />a. <br />Codes for Wastes <br />I <br />Listed <br />b. <br />Above <br />c- <br />d. <br />15. Special Handling Instructions and Additional Information <br />tz►�S � o � y-'�s� � /`�i . Ste- c,�r� � �� �G r� <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 cerlily 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, it I am a small quantity generator, I have made a good <br />faith effort to minimize my waste generation and select the best waste management method that is available to me and that I car afford. <br />ri to ped Name ign fur Month Day Year <br />OmT <br />T 7. Tr nsporte 1 Acknoalledgemenf o4 Reeeipt of Ma erials <br />R _ <br />A Print e Ty ed Name f!•j Signalure� Month Day Year <br />41 <br />P - _ <br />O 18. Transporter 2 Acknowletl em ' <br />et ReEeipl of Materials i <br />R Printed/Typed Name Signature Month Day Year <br />T <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 20. Facility Owner or Operator Cerlificaiion of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />YPrinted/Typed Name Signature Month Day Year <br />I I I I jII <br />DHS 8022 A (1 /H7) INSTRUCTIONS ON THE BACK <br />EPA 8700--22 Bluc: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />(Rev. 9.86) Previous editions are obsolete, To: P.O. Bok 400, So_.rerre7do, CA 45502 <br />IN CASE OF AN EMERGENCY OR SPILL, CALL THE NATIONAL RESPONSE GENTFR 1-800 424-8802, WITHIN CA[ IFORNIA CALL 1 1100-857-75S,O <br />