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:°IRte of Gatlfornla—Health and Welfare Agency <br />Pl sae print gr type. (Form dsstgned for use on slate (12•pltch) "writer.) <br />UNIFORM HAZARDOUS 1. Generaloes US EPA ED No. <br />WASTE MANIFEST C ? P D'761 .- <br />3. Ciener CWC Name and Mall -Ing Address <br />�CJ`J' <br />4. Generator's Phone ( } -~ (-= —5 `• _• 4 <br />5}. Transporter t Company Name <br />H 8• <br />T H S I•i I (� <br />7. Transporter 2 Company Name <br />US EPA ID Number <br />Department of Health 80Nces <br />Toxic Substances Control Division <br />Sacramento, Ce1110MIA.. ` <br />eat 2. Page 1 Information In thea at"$ <br />xt,N Is not_ required by Federal <br />of aw: <br />A. State Manifest Document Nu <br />V V f _+ -71- —7. <br />ryll•rNrx:. .r:. . <br />a. State Generator • 10 a 4w!,e , <br />- <br />K. Handling Codes for Wastes Listedf <br />," • <br />Q Stste Tmnaporter'a ID <br />D. Transportaes Phone <br />— <br />d .+ Y .a r/. ,•i <br />E. State Transporter's iD-:�:<,: <br />�' _ %}.yj� <br />F. Transporter's Phone <br />9. Designated Faclilty Name and Site Address 10. US EPA ID Number p state Fpcllityaa I <br />F1 LF— <br />f -,JA- E A 0 H.Faelll <br />12. Containers 13. 14.7 r€,'1f3r� r.+ <br />11. US DOT Description (including Proper Shipping Name, Hazard Glass, and !D Number) Total Unit <br />wwa � � tN>teie <br />No. Type Quantity .. <br />R � <br />A b- <br />R <br />C. <br />d. <br />••a <br />K. Handling Codes for Wastes Listedf <br />J. Additional Descriptions for Materials Listed Above a { ~r x, .. <br />F— K\7r, �y �#.1� 15 14 `� .l", 1 <br />d .+ Y .a r/. ,•i <br />� `T+1 .Y S�� r'..K fP tr s�i- <br />�' _ %}.yj� <br />.`fit <br />`7 y ,. � .r ':l�il <br />w <br />�h �fi�q�, <br />,N 4 ~t�'�'•a.'CF <br />.. . <br />15. Special Handling Instructions and Additional information <br />L <br />15. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by <br />proper shipping name and are classlfied, packed, marked, and labeled, and are In all respects In proper condition for transport by highway <br />according to applicable International and national govemment regulations. <br />Unless I am a small quantity generator who has been exempted by statute or regulation from the duty to make a waste minimization certification <br />under Section 3002(b) of iiCRA, i also certify that I have a program in piece to reduce the volume and toxicity of waste generated to the degree I <br />have determined to be economically practicable and I have selected the method of treatment, storage, or disposal currently available to me which r <br />minimizes the present and future threat to human health and the environment. <br />Printed/Typed Name Signature Month Day ear <br />T 17. Transporter t Acknowledgement of Receipt of Materials <br />R <br />A P t�Typed Name _ y Slgn ; Month Da yea <br />s fn <br />0 18. Trans porter 2 Acknowledgement of Receipt of Materials <br />T Printed/Typed Name Signature Month Day year <br />E <br />R I I r I i I I <br />sCrepanCy Indication Space <br />F <br />A <br />c <br />1 ' <br />1 <br />T 20• Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted In Item 19. <br />r <br />PrintedlTyped Name I Signature Month Dav Year <br />OHS 8022 A (11185) <br />4EPA 8700-22) <br />YELLOW GENERATOR RETAINS <br />