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Department of Health S <br /> State of California--Health and Welfare Agency Toxic Substances Control <br /> FornyApproved OMR No.2060-0039(Expires 9-30-. Sacramento,Cal <br /> Pleeae print or type. (Form designed for use on elit itch typewriter). <br /> 1. Generator's US EPA ID No. Manifest7A. <br /> Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS Document No. of snot required by Federa law. <br /> WASTE MANIFEST <br /> late Manifest Document Number <br /> 3. Generator's Name and Mailing Address897 -2,tate Generator's ID i <br /> 4. Generator's Phone( ) <br /> m 5. Transporter 1 Company Name <br /> & US EPA ID Number C. State Transporter's ID <br /> m D. Transporter's Phone <br /> r <br /> e. US EPA 10 Number E. State Transporter's ID <br /> m 7. Transporter 2 Company Name <br /> m F. Trenaporter's Phone <br /> 0 <br /> m <br /> 9. Designated Facility Name and Site Address /0. US EPA ID Number G. State Facility's ID <br /> J <br /> J H. Facility's Phone <br /> U <br /> 6 <br /> 2 12. Containers 13. Total - 14. I. <br /> ¢ <br /> Quantity Unit Waste No. <br /> U 11, US DOT Description(Including Prober Shipping Name.Hazard Class,and ID Number) No. Type Wt/Vol <br /> LL <br /> � State <br /> Q <br /> if X. fl <br /> tA' r)C'� <br /> Z EPA/Other <br /> G <br /> 00 3 N State <br /> E b. <br /> o R EPA/Other <br /> m A <br /> m T <br /> v O LEPA10ther <br /> V <br /> R c. <br /> o <br /> CP <br /> W d. <br /> Z <br /> W <br /> U <br /> K. Handling Codes for Wastes Listed Above <br /> W J. Additional Descriptions for Materials Listed Above a b, <br /> Z <br /> N )"'i 19 f7BtE )r d <br /> W C. . <br /> Q <br /> J <br /> Z <br /> Z <br /> O <br /> f. 15. Special Handling Instructions and Additional Information <br /> Z <br /> 2 <br /> H <br /> J <br /> 16. <br /> U <br /> eclare that the contents of this consignment are fully and accurately described above proper shipping name <br /> � GENERATOR'S CERTIFICATION: I hereby d <br /> ,1 and are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable <br /> icable internetionel and <br /> N <br /> national government regulations. <br /> ¢ If 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 /> U to be economically practicable and that I have selected the practicabll ee small trt ie t,storage, I have made aJisosal rrgooltl faith effort to minhmize mywaste <br /> minimizesy available to me wich the <br /> present and future threat to human health and the environment;OR, amqea <br /> U generation and select the best waste management method that is available to me and that 1 can afford. <br /> Z Signature Month Oey Yeer <br /> w Printed/Typed Name <br /> U <br /> W <br /> y�j T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R Signature Month Day Year <br /> Z< A Printed/Typed Name <br /> N <br /> O S <br /> P 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> w O Month Dey Yeer <br /> of< R Printed/Typed Name Signature <br /> U T <br /> E <br /> 2 <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certificatlon of receipt of hazardous materiala covered by this manifest except as noted in Item . <br /> T Month IT-3, Year <br /> y Printed/Typed Name Signature <br /> DHS 8022 A(1/88) Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9.88)Previous editions are obsolete. YELLOW: GENERATOR RETAINS <br />