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L) <br />U <br />Z <br />O <br />LL <br />J <br />Q <br />U <br />2 <br />F <br />3 <br />N <br />op <br />m <br />N <br />N <br />a <br />0 <br />0 <br />m <br />w <br />Z <br />Z <br />U <br />w <br />W <br />Z <br />O <br />0 - <br />On m <br />Ju <br />CrJ <br />Q <br />Z <br />O <br />1- <br />Z Z <br />z <br />J <br />J <br />Q <br />U <br />J <br />J <br />a <br />!n <br />O <br />State of California -Health and Welfare Agency Department of Health Service: <br />Fora Approvp l OMB No. 2050-0039 (Expires 9-30 Toxic Substances Control Divisioi <br />e <br />,ease <br />prrrc oiype. trorm oesrgneo ror use on a z-pncn rYpewnreq. <br />___. _..._..._, __... _..... <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. <br />Manifest <br />2. Page 1 <br />nformation in the shaded areas <br />WASTE MANIFEST <br />Document No. <br />of <br />is not required by Federal law. <br />3. 1 ralorpN !;rk ling Address <br />,41 <br />r 1 7�/)G if Aw' 1 (y `r 4erryt <br />,� r <br />A. State Menlfys .pgW�rlWWpt�1 <br />IIID Jt�i <br />/,J <br />5 K j �.c� fq ^ - -) <br />.� <br />B. State Generator's <br />4. Generator's PhonoZI ) I.%... 7y ��" 7 <br />j <br />� �... <br />1 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporters ID <br />r 1 ( r <br />D. Transporter's Phone -.. -.r ..... <br />7. Transporter 2 Company Name 6. US EPA ID Number <br />E. State Transporter's ID <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />I • ,- <br />r- <br />H. Facility's Phone <br />1 1-.• ^ • <br />t <br />12. Conte inere <br />13. Total <br />14. <br />I. <br />/1. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity <br />Unit <br />Waste No. <br />No. Type <br />Wt/Vol <br />y[ <br />EPA/Other <br />G <br />1I1, <br />N-LLi-LL1 <br />E <br />b. <br />Slate <br />R <br />A <br />T <br />EPA/Other <br />O <br />R <br />c. <br />Slate <br />EPA/Other <br />d. <br />State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />a. <br />b. <br />C. <br />d. <br />15. Special Handling Instructions and Additional Information <br />f_1, a. rlii'i a t i T+e: `;L.1'F <br />18. <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 in proper condition for transport by highway according to applicable international and <br />national government regulations. <br />If 1 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 end 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, I have made a good faith effort to minimize my waste <br />generation and select the best waste management method that is available to me and that I can afford. <br />Printed/Typed Name I at f,.� <br />( <br />Signature Month Day Ye. <br />'I / <br />f <br />T <br />R <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />A <br />Printed/Typed Name <br />Signature Month Day Yew <br />S <br />P <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />Printed/Typed Name <br />Signelure Month Day Yee <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />y <br />Printed(T ped Iflamp <br />Signature Month Day Ye. <br />DHS 6022 A 0 /BS) <br />EPA 6700-22 <br />(Rev. 9.66) Previous editions are obsolete. <br />Do Not Write Below This Line <br />YELLOW: GENERATOR RETAIN, <br />