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State of California--Health and Welfare Agency Department of Health Services <br /> Form Approved OMB No.205D-0039(Expires 9.30-9 Toxic Substances Control Division <br /> Please print or type. (Farm designed for use on elite itch I'pewrher). 0 Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Paget nformation In the shaded areas <br /> Document No. <br /> WASTE MANIFEST , ( r ft I II I of 11 is not required by Federal law. <br /> 3. Generator's Name and Melling Address A. Slate Manifest0 cu en Number <br /> PlnatkcG. Inc . 8 �6 2032 <br /> 2129 E. Taylor B. State Generator's ID <br /> "00'17011 - Ca.11furula 99205 <br /> a. Generator's Phone(?/9 ) 163 7793 <br /> yj 5. Transporter 1 Company Name 8. US EPA ID Number C. Slate Transporter's ID <br /> N <br /> V IAID I'1 I A I i I 1:I q D. Transporter's Phone r <br /> N <br /> io 7. Transporter 2 Company Name B. US EPA ID Number E. State Transponer's ID <br /> p 1 1 1 1 1 1 1 1 1 1 1 1 F. Transporter's Phone <br /> m <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number O. Slate Facility's ID <br /> Erickson. luc. <br /> NQ 259 Parr Blvd. <br /> a RichH. Facility's Phone <br /> M mond, Ca. 9dS01 <br /> CZ 111 o In I vi I I I A I A I I'I I n f I — 1r <br /> C, M 12. Containers 13. Total 14. I. <br /> 0 11. US DOT Description(Including Proper Shipping Name,Hazard Claes,and ID Number) Ouentity Unit Waste No. <br /> 7 a.. No. Type Wt/Vol <br />[�U a. State <br /> Z G Uudergrloud Stnrage Tnuk t12 <br /> oOE CaIj[0rniu Regulated Waste 0nty T EPA/Other <br /> 3 N I T P II t n fi o P Nous <br /> E It. State <br /> 3 R <br /> A <br /> m T EPA/Other <br /> N O <br /> R C. $lelb <br /> EPA/Other <br /> W d. Slate <br /> Z <br /> W <br /> U EPA/Other <br /> w <br /> Z J. Additional Descriptions for Materiels Listed Above K. Handling Codes for Wastes Listed Above <br /> e, b. <br /> a Empty diesel tank. 42617 <br /> ¢ iced with 30 lbs. dry IceC. d <br /> J <br /> Q_ <br /> 0 <br /> QI5. Special Handling Instructions and Additional Information <br /> Z <br /> =W <br /> J <br /> V 18. <br /> J GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J and are classified,pecked,marked,and labeled,and are In all respects In proper condition for transport by highway according to applicable international and <br /> Wnational government regulations. <br /> It I 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 determined <br /> p to be economically practicable and that I have selected the practicable method or treatment•storage,or disposal currently available to me which minimizes the <br /> > present and future threat to human health and the environment;OR,It I am a small quantity generator,I have made a good faith effort to minimize my waste <br /> V generation and select the beat waste management method that Is available to me and that I can afford. <br /> WPrinted/Typed N Signature 11 Month Day Year <br /> W J <br /> WTR 17. Transporter t Acknowledgement of Receip of Materials <br /> O 9 Printed/T e�L1 ^ �/ �1 Sipnatdrr A� Month Day Year <br /> Ti C/J / <br /> W O 18, Transporter 2 Acknowledgement of Receipt of Materials <br /> UT Printed/Typed Name Signature Month Day Year <br /> E <br /> Z <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 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 Month Day Year <br /> DHS 8022 A(1/88) Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. <br /> YELLOW: GENERATOR RETAINS <br />