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State of Califomia—Health and Welfare Agency a. <br /> Form Approved OMS No.2050-0039(Expires 9-30 9 9 Department of Health Services <br /> Be, tint 01 t e; 6 Toxic Substances Control Division <br /> `. (Form tlasi netl for use on alit itch+ ewrifer). r x �. ('"a k Sacramento, California <br /> UNIFORM HAZARDOUS Generator's US EPA ID No. <br /> WASTE MANIFEST C L J 1 i C em ntormation in the shaded arses <br /> r� '^ o not required by Federal law. <br /> 3. Genet fo//r��s Nab§aM Mating AdtlreSs + A Slej <br /> 1 Y+S t, ''(j,N CGL k i cl`"� ,(fr.L..� ar ani cu en Number <br /> si <br /> I T <br /> "hone f "5 �e _ B Stets Gen <br /> a. Generator's Phone <br /> { 5. Transporter 1 Company Name t 8. US PA Ip N mblar C Stale Tranaporter'e ID <br /> U �( r Tranaporter'a Phone s j <br /> C <br /> 7. Transporter 2 Company theme e. .US EPA ID Number E. State Transporter's ID - <br /> F. Transporter's Phone <br /> 9. Desnated Faity Name enSite Address ,., 10. US EPA ID Number G. State Facility's ID " <br /> ras-s Pa !Z. µj <br /> 7 ( H. Facility's Phone <br /> ,'�`C".4 I ,Lr,,r.. C 1 '��V� I• L 1y L� (, C.l f�� � rr'3 r, <br /> !' 12. Containers 13. Total 14. <br /> 11. US DOT Description(Including Proper$hipping Name,Hazard Class,and ID Number) Quantity Unit We iste No. <br /> r1`aT E L i— O (" No. Type Wt/Vo <br /> y �-k-...9.�5 E State <br /> IS / 12 <br /> N ,,. q Y< C��. It'.TC f:". ��rn>}�e ��-rt L_I !a L�e� TI "' / Y�21J p EPA/ilOthe�_ <br /> E b. <br /> Rr. State <br /> {iE O - ri{�J U 7J 9 J -� EP her <br /> l <br /> R c <br /> � �J .-i stela <br /> Jq� , <br /> EPA/Other , <br /> d. N <br /> state <br /> E '✓1e Vii` C.1T <br /> a c QUIP;a,ItfWT ��' CEPAlane( <br /> J. Additional Descriptions for Materials Llate <br /> y11 K Handling Codes for Wastes Listed Above <br /> 4 1 r Ta L a b. <br /> 1. V �w>1 4V✓ 1115 YV � r.�.'�r. fiR'\S ta0. f <br /> s <br /> 15. Special Handling[netruchons and Additional Information - <br /> 18,. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> name and ere 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, 1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I havif <br /> determined to be econcmic.=_Ily practicable and that 1 neve selected the practicable method Of treatment, storace, or disposal current!v available to <br /> me which minimizes the present and future threat to human health and the environment; OR, if 1 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 can afford. <br /> Pr('n�ed/Type N Sign / q <br /> 1" t CU� ���: / tea �.� _ L MontDay <br /> I p P. Tr sorter / Acknowledgement of Receipt of Materiels <br /> I. A Prin d y ed Ne /,,.(} Signature Month DeyQY <br /> s ��/ / )Gd O %a l J <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> RPrinted/Typed Name Signature <br /> E i Month Day Year <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> ttF L <br />` -1 20, Facility Owner or Operator Certification of receipt of hazardous materiels covers y is anifeat except as notedIle 19. <br /> f TPrinted/Typed NameSignature <br /> ,y Month Day Year <br /> DHS 8022 A(1/87) RUCTIONS ON THE BACK Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS �(I)S <br /> t EPA 8700-22 l(� r <br /> t (Rev.9-86) Previous editions are obsolete. <br /> 7 � <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 /> 1 <br />