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State of Callforple—Health and Welfare Agency <br />form Approved OMB No. 2060--0030 (Expires 9-30-W1 <br />Please print or Woe. (Farm r dealoned for use on e�-.Itch f.awril 1. <br />i <br />Department of Health Services <br />Toxic Substances Control Division <br />Sacramento, California <br />DHS 8022 A (1/88) Do Not Write Below This Line <br />EPA 8700-22 YELLOW: GENERATOR RETAINS <br />(Rev. 9-88) Previous edittone are obsolete. <br />. generator' U EPA ID No. <br />UNIFORM HAZARDOUS <br />Af <br />Menifeet <br />p <br />2. Page 1 <br />the shaded areas <br />WASTE MANIFEST <br />`Dole <br />V f <br />of / <br />a not reion quirin <br />ed by Federal <br />3. Generator's Name and Melling Address `` 11 <br />:1 ri [ �� �, 11 i Ii(1 K�'` (.'�inL�t r71 �'-V11c <br />A. State Manifest D#cu a N��y7ym r <br />� V 03 <br />4f <br />`•;/r L1�a11q-� <br />R. State generator's ID <br />,� 1, . <br />4. generators Phone (I j -r 3 �-� <br />6. Transporter 1 Company Name 8. US EPA ID Number <br />C. State Transpoder'e ID fr <br />0. Transporter'e PMne <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID <br />F. Trenepoder's Phone <br />I. Designated Facility Name and Site Address 10. US EPA ID Number <br />O. State Faolley's ID <br />biakew Int. <br />H. FaclMy's Phone <br />1) 'P <br />2" � Blvd* <br />s•N <br />JUAMMai CA 6111 r-AinininivAidid <br />12. Conteinere <br />13. Total <br />14. <br />1. <br />11. US DOT Description (Including Proper Shipping Name, Hazard Claes, and ID Number) <br />Ouantity <br />Unit <br />Waste Ne. <br />No. Type <br />Wt/Vol <br />a. <br />Star+„e <br />WWW 11111111pty (it=W rte__ <br />E�[QI_er <br />EWW' <br />O <br />N <br />calilemu �Lated deft! Only <br />, <br />TIP <br />)6joipp <br />E <br />b. <br />state <br />R <br />A <br />T <br />_ -A <br />EPA/Other <br />O <br />R <br />c <br />Slate <br />EPA/Other <br />d <br />1 <br />Stele <br />EPA/Other <br />E41TH <br />J. Additional DISCHptl0nMaterials boOq p <br />i for Matls Listed Ac' \ /) � ..yr. L✓ <br />E, . 7� )etA t / <br />K. Handling Codes for Wastes <br />a.C. <br />Listed Above <br />b. <br />7 f/ A <br />d.16. <br />Special Handling Instructions and Additional Information <br />y� ••�� `_ ,,1� <br />of Wtiou M� v date Ohm <br />"&my r�� <br />16. <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br />and are classified, packed, marked, and labeled, and are In all respects M proper condition for transport by highway according to applicable International and <br />national government regulations. <br />K 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 />to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the <br />present and future threat to human health and the environment; OR, If I am a small quantity generator, 1 have made a good faith effort to minimize my waste <br />generation and select the beet waste management method that Is available to me and that 1 can afford. <br />Printed/Typed Name <br />Signs urs Month Day Year <br />y:.:.c...-..... <br />l.. <br />I... <br />Y <br />/ ) <br />1 <br />� 1 1� r ICA I <br />t <br />T <br />R <br />17, Transporter 1 Acknowledgement of Receipt of Materiels <br />A <br />PdntedfM of N'me 1 / <br />Signat e <br />1 Month Day Year <br />P <br />O <br />le. Trenepoder 2 Acknowledgement of Receipt of M erlela Jor <br />R <br />T <br />Printed/Typed Name <br />Signature Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />L <br />I <br />T <br />20. Faclllty Owner or Operator Certification of receipt of hazardous materiels covered by this manifest except as noted in Item 19. <br />y <br />I Printed/Typed Name <br />Signature Month Day Year <br />DHS 8022 A (1/88) Do Not Write Below This Line <br />EPA 8700-22 YELLOW: GENERATOR RETAINS <br />(Rev. 9-88) Previous edittone are obsolete. <br />