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State Of Cdtorrfa—Health and Welfare Agency - Department of Health Sewlces <br /> See Instructions on back -1 page 6. Toxic Substances Control Program <br /> please prrN Or type. Form dealgned for Lee on&tale 02-P pewrflerx Sacrarnenio.California <br /> UNIFORM HAZARDOUS 1 Generators LIS EPA ID No. ma"N t Do--No. 2-Page 1 Irrounation in the strolled areas <br /> WASTE MANIFEST C A, DI 9, 81 11 31 bl 9, 91 910 , 1101or 1 is not recIuved by Fedetal law' <br /> 3.Generators Name and MOAN Address <R Skate marfest Document Nxnbe9 1 5 5 2}rt <br /> LODI S. <br /> M L TM. CALIFO MA 95242 ��Jk <br /> Z13 S. IIQd.Z 9T. n * �y <br /> 4 Generators Phone(�) 334-25W ii :. l J 1 4J I i f 4 t fr 4 9i <br /> 5.Transporter 1 Company Name 6.US EPA ID Number C,9rate'#ttrxplstbrf't 0 <br /> B.O.R. IMMSTRIM CIA ID 11 1012 jS12,715 19,9 774""""phone M-2342, <br /> 7.Transporter 2 Company None B.US EPA ID NumberSIY7keTYfripotters 1C) ' <br /> Phone <br /> 9.Desprxated Focity Name and Site Address 10.lb EPA ID Number > ${ „ pyl,D. <br /> SUPWT INVIROMMIMAL CM.0 31M <br /> Co <br /> W1BR08 RD. I I 10 18 1 I I 16 171L <br /> 12.Coritainers 13 Total 14.UWf '' 3 <br /> 11.US DOT Description(Including Proper Shipping Name.Hazard Class.and ID Number) No. Type Quarittly WtNdCL <br /> :`•.; Wcate N xnt»r <br /> f.�,al►err-.. C.ar..Av�r.r�t v 'C��ut�s Nam <br /> U G 1q9 <br /> E <br /> Eb. <br /> In a q 1 1 <br /> _U T C. Stere' <br /> LCA= o <br /> R A/Ornej <br />/� <br /> V/C;; d : .. <br /> 0 <br /> Co <br /> J.Addrtrond Descnotarn for Materbts Lalad Above '. !�fiardlYgCodes for Wasies.Listed Above <br /> `. <br /> c <br /> a <br /> .; <br /> C <br /> _. <br /> (� 15.Special Handling Inshuctions and Additfond Information <br /> LJ <br /> V) +� 3 co 'ita.s 7 <br /> O <br /> a <br /> c WEAR GLOVES & ramEy"VE MOWN <br /> J <br /> Q 16. GENERATORS CERTIFICATION: I hereby declare that the contents of this consignment oro fully and accuratey described above by proper shipping name and are clmsfied. <br /> Z packea marked.and iabeied,and are Ind respects in proper condition for transport by highway according to appicabie International and nationci govenrnent regulation:. <br /> O <br /> QIf I am a forge quantity generator.I certlfy that I have a program n place to reduce the voiume and toxicity of waste generated to the degree I hove determined to be <br /> Z econortfcaily practicable and that I have selected the practicablenr <br /> method of treanert,storage.or disposal currently avaiable to me whichnt n**nbm the preseand future <br /> w threat to human health and the erwonmert:OR.If I am a srrtai quaMlfy generator.I have made a good faith effort to minimb s my wrote generation and select the best wale <br /> = managertwrt method that it available to me and that I can afford <br /> J <br /> Pnnted/Typed Name Signature Month <br /> Q Year <br /> U l <br /> //?V <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> C <br /> O R Printed/Typed Name Month Day year <br /> y A <br /> Q NS BeO.R. IlIT Is1BIB8 1 013 1 1 1 91 2 <br /> Ur P <br /> C 0 1 B.Transporter 2 Acknowledgement of Receipt of Matenob <br /> R Printed/Typed Name Signature Month Day Year <br /> Lu T <br /> O E <br /> w R <br /> QDiscrepancy F 19.DisepaniSpaceication Space <br /> U A <br /> Z C <br /> I <br /> L <br /> 1 20.Facddy Owner or Operator CertiRcanan of receipt of hazardous materrab covered toy this manfert except as noted in item 19. <br /> Prnted/T Ped Nome Signature Month Day Year <br /> i�i� I I I I <br /> DON RRE B 4ISUWE. <br /> s: <br /> DHS 8022A(12/90) Blue: GENERATOR SENDS TF 11S COPY TO DHS WITHIN 30 DAYS. <br /> EPA 8700-22 To: P.O.Box 400.Sacramento.CA 95812-0400 <br />