Laserfiche WebLink
Stale of California—+iealth and Welfare Agency <br /> FDepartment of Health Ser. <br /> Form Approved OMB No.205[1~0039(Expires 9-3t),-,) Toxic substances Contra)Dr. <br /> Plea•a tint or type (Form designed for use ort t?- itch r ewnter). Sacramento, r ,i,. <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID Na Mal 2. Page 1 <br /> r. L-y Document No. Information in the shaded ar+-:, <br /> WASTE MANIFEST J — of is not required by Federal law <br /> 3 ,GelwlJrlgr'n JJam+�nd Mail i iy Address A. Stale Manifest Document Number <br /> lelj <br /> /// B. State Generator's ID <br /> 4 (:enr:r:iirir'&Phone Fq.<<) � / f,j � �f �/S }�-•L/ <br /> / rod yr - - ST <br /> J ri, ,,,p4 lgr t.Com ung Nam' - —.-- <br /> ri 1 FJ� 6 US EPA ID Number C. State Transporter's IDS• ') <br /> 7 I <br /> " tell (, � / 'l D. Tranaparter'e Phon f C <br /> 7 Transpottei 2 Company Name 8, US EPA ID Number / ..0 '- <br /> / E. State Transporter's <br /> F. Tranaporter's Phone <br /> ~ G <br /> 9 Des,geafed Facility Name and Site Address 10. US EPA ID Number G. Slate Facility's ID <br /> H. FibQ'illy'a P one <br /> 11 US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number 12. Container 13. tai 1nit I <br /> in <br /> � } Quantity Unit Waste No. <br /> ¢ No. Type Wt/Vo <br /> a { �e �-- Q <br /> z G LL ter'}� C''l I r�s��c;.5 1 ! IG� stare <br /> E <br /> ~ N �� t <br /> z L �.� EPA/Other <br /> E b. _ <br /> R State <br /> 0 <br /> M A <br /> v T EPA/Olher <br /> cv p <br /> ao R c State <br /> W <br /> EPA/Other <br /> LU d. <br /> ti <br /> Z Stela <br /> w <br /> U <br /> w EPA/Other <br /> Z I J Additional Descriptions for Materials Listed Above <br /> K. Handling Codes for Wastes Listed Above <br /> O <br /> u a. b. <br /> A <br /> Lr <br /> c. d —� <br /> z + <br /> 0 <br /> a <br /> 15.'Special Handling Instructions and Additional Information <br /> Z <br /> LU <br /> 2 <br /> H <br /> J <br /> r 16. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above b <br /> name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport b highway y Proper shipper, <br /> ' R P P R Y Q Y accarding to applir.;,t,l,: <br /> d international and national government regulations. <br /> U) I1 I ani 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 he f <br /> determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently availdbIt' l- <br /> me which minimizes the present and future threat to human health and the environment: OR, if t am a small quantity> q y generator, 1 have made a yoa.I <br /> lash effort to minimize my waste generation and select the bust waste management method that is available to me and that 1 can afford. <br /> U <br /> Z <br /> W Printed/T id lame C7 Signature Month Clay YeLu <br /> ,. <br /> LL n <br /> Lu T 17. Transporter 1 Acknowtedgeme t o1 Receipt of Materials J <br /> R <br /> ¢ A Printed/T d ame N Signature 7 Month Day 1'.•. <br /> S <br /> 0 <br /> O P <br /> w <br /> O. 1e. Transporter 2 Acknowledgement I Receipt a1 Materials - <br /> U) <br /> T Printed/Typed Name Signature Month Day Yv,. <br /> U E <br /> Z <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> f 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name <br /> Y Signature Month Day Yuri, <br /> I I 1 I <br /> DHS 8022 A(1187) 'J3 T,�.:, ='Jr'r 1G i�V1;:, `J.:,Fi�.'� „J UrS.Y.', .. <br /> EPA 8700-22 INSTRUCTIONS ON THE BACK <br /> (Rev. 9-86) Previous editions are obsolete. To: i'.C). Box 300J, SoCrornento, CA 95812 <br />