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' Siete of California- Heatth and Welfare Agency- <br />' pForm approved OMB No. 2050-0039 (Expires 9 - <br />Pie Be <br />-Plaaae rinl or type. Form desi ned for use on -itch ! ewrifer). <br />' UNIFORM HAZARDOUS E rINX r Manifest <br />WASTE MANIFEST <br />3. <br />, nerato�r•s:�Name and M•ai[l AwarkA„dd€ rWI`Nj f it fj <br />4. Generator's Phone <br />.. „� 1-, <br />y , IFiT!S. (lit <br />P Phone <br />5 Tr porter i Company Na 6. US EPA ID lifilNuMper <br />7. Transporter 2 Company Name B. US EPA ID Number <br />G <br />E <br />N <br />E <br />R <br />A <br />T <br />O <br />R <br />9. nRated Facility (Awe and Site Address 10• <br />D <br />F,44 71420 A(P, 6*4 . 1i 3 A3 I C� <br />US EPA 1D Number <br />Inc/' l i ZI 4'6I r <br />11. US DOT Description (including Proper Shipping Name. Htazard Class, and IDI Number) <br />"yc' <br />b. <br />J- Additional Desgriptions for Y- <br />12, <br />rials Listed Above <br />WATM i <br />Cont <br />No. <br />/ Department of Health Services <br />Toxic Substances Control Division <br />Sacramento, California <br />2. Pag 1 jnforrngtion in the shaded areas <br />of is not required by Federal law. <br />A. State Manifest Document Number <br />83821369 <br />B. tate Gen r ar'ti ID �..� <br />ll <br />C State Tranaporter's 1D �' ��` `l <br />D. Tranaporter'sPhon } �;_, �'' <br />E- State Transporter's ID <br />F. Transporter's Phone <br />G. State Facility's ID <br />CIATDI 01 <br />H. F <br />dity's Phone <br />r 1 <br />riners <br />Q. Total <br />Quantity <br />14- <br />Unit <br />I. <br />Waste No. <br />TypeWtlYo <br />Stab' � <br />State <br />EPA/Other <br />State <br />EPA/Other <br />State <br />EPA101her <br />K. Handling <br />Godes or Wastes <br />Listed <br />Above <br />a. <br />� <br />b. <br />C. <br />d. <br />y 15. Special Handling Instructions and Additional Information <br />Aj <br />18. <br />t GENERATOR'S CERTIFICATION: i hereby declare that the contents of ibis 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 1 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. I have made a good <br />faith effort fo minimize my w;�ate generation and select the hest waste management method that is available to me and that I can afford. <br />month Day Year <br />Printed/Typed Name Signature <br />T ' 17. Transporter 1 Acknowledgement of Receipt of Materials M <br />R Year <br />A Printed/Typed'Name Signature onth Day. <br />P <br />O 18. Transporter 2 Acknowledgement of Receipt of Materials <br />R PrintedrTyped Name Signature Month Day Year <br />T <br />1= <br />19. Discrepancy Indication Space <br />F <br />A <br />G <br />1 20. Facility Owner or Operator Certification of receipt of hazardous materials co red this manifest except as ted Item 19. <br />NY <br />h Day_ year <br />T ted/Typed Name Signator % � r /�' fr L: <br />1 <br />DHS 8022 A (1187),._ GREEN: HAULER RETAINS. INSTRUCTIONS ON THE BACK <br />(;` <br />EPA 87022 <br />(Rev. 9-66) Previous editions are obsolete- <br />IN CASE OF AN EMERGENCY OR SPILL. CALL THE NATIONAL RESPONSE CENTER 1-800-424-8802; WITHIN CALIFORNIA CALL 1-800-852-7550 <br />