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®d <br />N <br />O <br />co <br />ec <br />v <br />N <br />V <br />O <br />O <br />m <br />cc <br />W <br />Z <br />z <br />W <br />U <br />W <br />W <br />Z <br />O <br />' 4 <br />W <br />W <br />iY <br />J <br />J <br />a_ <br />c.7 <br />fY <br />O <br />} <br />u <br />Z <br />W <br />0 <br />ccW <br />i <br />W <br />Z <br />a <br />LL <br />O <br />W <br />rn <br />Q <br />L) <br />State of Califorpia—Health and Welfare Agency Department of Health Services <br />Forwt.Approved OMB No. 2050039 {Expires 9 30 Toxic Substances Control Division <br />P[easp Qrint or type. (Form designed for use on alit* -pitch typewriter). 0 Sacramento, California <br />DHS 8022 A (1 186) <br />EPA 8700-22 <br />(Rev. 988) Previous editions are obsolete. <br />Do Not Write Below This Line <br />YELLOW: GENERATOR RETAINS <br />UNIFORM HAZARDOUS <br />. Generator's US EPA ID No. Manifest <br />2. Paget <br />Information in the shaded areas <br />WASTE MANIFEST <br />Cl 1 "i -1 Document No. <br />4'a I (1 .-� � fi, <br />of <br />is not required by Federal law. <br />q <br />3. Generator's Name and Mailing Address <br />A. State Manifest Document Numberrr�� <br />89460920 <br />:306 L sctta DrivFs <br />B. Slate Generator's ID <br />i CA 9 s 2.1 <br />4. Generator's Phone( ) 0 (1 � 6 �3 � i!) I r <br />C.1 6 ri On� � i4 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID <br />! l r i L' f l j l i1 1 l i . Z i ;;� .• {� Zi TZ ? ; :; 7 4 ' r. I? 7 <br />D. Transporter's Phone <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />s <br />E. State Transporter's ID n h f1"7 -Z� Ir <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />Recyclotron joiI, Inc <br />t 1�1, .1 1 1• I I �, -11 17 1 <br />13331 North T1igii(,tay 33 <br />s Phone <br />H. Facility's <br />y' <br />7 71 r� Al* <br />r:, i3 t t 0 t ::r '.) � I , 1C.. A J 7-, .3 C � r A1! cl i � �i �.� � � F� <br />� .' l : 9 ) f? i? f s <br />12. Containers <br />13. Total <br />14. <br />I. <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity <br />Unfit <br />Waste No. <br />No. Type <br />Wt/vel <br />a. <br />State <br />. :L i <br />G <br />,^ <br />_ <br />EPA/Other <br />E <br />b. <br />State <br />R <br />A <br />T <br />EPA/Other <br />O <br />R <br />C. <br />State <br />EPA/Other <br />d. <br />State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />a. <br />b. <br />C. ..., <br />d... .;..;r <br />JAN <br />3 1.90 <br />C2 <br />15. Special Handling Instructions and Additional Information �.''v MENTAL HEALTH <br />PERMIT/SERVICES <br />16. <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 />national government regulations, <br />If faro 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 determined <br />10 be economically practicable and [hat 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 t am a small quantity generator. I have made a good faith effort to minimize my waste <br />generation and select the best waste management method that is available to me and that I can afford. <br />Printed/Typed Name <br />SignalVe Month Day Year <br />T <br />R <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />A <br />Printed/Typed Name Signature Month Day Year <br />N <br />! <br />:, /l" f.r:{,,fir . rrILI 1011' n '? <br />P <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />Printed/Typed Name 1, C <br />.�y'`t f�Vt�CI t- ��a <br />Signature Month Day Year <br />E <br />19. Discrepancy In ication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />T <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />Y <br />Printed/Ty ecd Name l <br />Signature t,' , tY fr / Month Day Year <br />rr <br />41'•1 I I II (6 <br />DHS 8022 A (1 186) <br />EPA 8700-22 <br />(Rev. 988) Previous editions are obsolete. <br />Do Not Write Below This Line <br />YELLOW: GENERATOR RETAINS <br />