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State of California--Health and,Welfarg Agency Department of Health Services <br /> Form Approved OMB No-280 -'0039,(Expires 9.90 81).:-- Toxic Substances Control Division <br /> -goese print or type (Form designed for use on elite(12-pitch typewriter). Sacramento.California <br /> U&MOHAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Pape 1 Information in the shaded areas <br /> ocumegt No. <br /> WASTE MANIFEST (, i) c1 Ct 1 '7 of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest D c Ng mbar <br /> -- 899329 <br /> B. State Generator's ID <br /> 4. Generator's Phone <br /> ,0 5. Transporter 1 Company Name 8. US EPA ID Number C. State Transporter's ID , t- <br /> 0 <br /> _. _ _ 4 D. Transporter's Phone <br /> N <br /> 0 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> CP <br /> o 1 1 1 1 1 1 1 1 1 1 1 F. Transporter'.Phone <br /> m <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID .i ll 0 <br /> 10 <br /> 7L 9f 12 'i 1'A SG:3 s"1 alt t a1 H. Facility's Phone <br /> Y)z -` :�1 r 7 J 31 of1 (7 (11 702-553-220 <br /> X)� 12. Containers 13. Total 14. I. <br />`0 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt/Vol <br /> Ua. State <br /> 3( E ,i... .�-i .� .s .�.T�_la { � .; ! D �'1 EPA/Othw.,1 <br /> N ©► 4f+ ql 61010 <br /> Rb' State <br /> o <br /> A <br /> n T i �.r ^� p EPA/OtAYWher <br /> N O a. L t4 T`..., ,s., l\ W ..•.' t a (J IC n' I 0 OVC Fn <br /> ,T R C. <br /> State <br /> 0 <br /> 0 <br /> m <br /> EPA/Other <br /> Cr <br /> Lu d. State <br /> Lu <br /> Z <br /> Lu <br /> U <br /> EPA/Other <br /> Lu <br /> U J. Additional Descriptions for Materials Listed Above ,f:r r <br /> Z T+ Ft ( K. Handling Codes for Wastes Listed Above <br /> Or^ b.: <br /> � .,�..�1:i S�1,..Vii`"1 it. t"J cit..•K�!' i:► . <br /> W a�-oU�-Ti'�aa <br /> ¢ ASS"3' ST:. Ali .DESCAPP ION: r:J�iTL`R BASEi�AIIu'I' a. d. <br /> ¢ ` <br /> 15. Special Handling Instructions and Additional Information <br /> Z <br /> W <br /> F=- <br /> TF f <br /> ., <br /> ¢ 18. <br /> U <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> CL national government regulations. <br /> in <br /> If I am a large quantity generator,I certify that I have a program in place!o reduce the volume and!=;o y of waOle ganera:eC to ti-.e degree i have determinea <br /> O to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> } present and future threat to human health and the environment;OR,if I am a small quantity generator,1 have made a good faith effort to minimize my waste <br /> U generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> WPrintedlJyped Name Signature- <br /> 0Month Day Year <br /> W �- J t i -�- <br /> WT 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> N Printed/Typed Name ..� Month Day Year <br /> Z � <br /> ¢ Signature <br /> LL S <br /> 17� , n <br /> w O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> U yped Name Month Day Year <br /> R <br /> ¢ T Printed/Typed Signature <br /> E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> C <br /> I <br /> L <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T <br /> y Printed/Typed Name Signature <br /> ` / Month Day Year <br /> CHS 8022 A(1/88) Do Not Write Below This Line <br /> EPA 8700-22 <br />(Rev.9-88)Previous editions are obsolete. <br /> Yellow: TSDF SENDS THIS COPY : :2NERATOR WITHIN 10 <br />