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stereofGaatornia--Health and Welfare Agency a <br /> Form Approved OMB No.2050-0039(Expires 93Department of Health <br /> 0.59) <br /> .I Please tint ort Toxic Substancesofn. Form desi ned for use on afire 12- itch Control t ewriter. Sacramento,C. <br /> UNIFORM HAZARD 1. Generator's US EPA 10 No. ifest 2. Page I <br /> ' J*em I Information in the shaded ar, <br /> WASTE MANIFE$ /� G U / of .r is not required by Federal Ia. <br /> 3. �jen�(tor'q Napya antl 711ing Address / A. State Manifest Document Number <br /> l'C /c..Y, P�jaX l� <br /> r 1; <br /> 5,4. Generator's Phone P;Yj) 5-2 , �L,/ /~ <br /> o 6,.Trahaponer Company Nama S. US EPA ID Number C. Stste Tmna onar'e 10 t;- <br /> N <br /> ^. - D. Trenaporter's Phone <br /> m7. Tra aporter 2 Company Nerge 8. S EPA ID Number E. Stale Transporter'a1 <br /> C d F. I ransponer'a Poon <br /> m 9. Designated Facility/Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> a OC//Ci)7,U <br /> U / / ' hl acility'a Phone <br /> 12. Containers 11� of 14. I. <br /> O 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and 10 Number) - Ouentity Unit Waste N. <br /> ILL <br /> .� No. I Type Wtivo <br /> U e. 'k I .,[/ I <br /> Vv > Gr <br /> E T , <br /> I F N 1 -20 1 1 TT 1i <br /> EP /Olnnr <br /> 3 E b. <br /> N R State <br /> O A 1 <br /> m T EPA/Other <br /> e O <br /> v R C. <br /> o Stara <br /> m <br /> EPA/Other <br /> w d. <br /> w State <br /> H <br /> Z <br /> U r Gr � EPA/01h., <br /> MZ J. Additional Descriptions for Materials Listed Above ! w. K. He as or i <br /> a. b. <br /> 100W JA A/ <br /> low <br /> C. d. <br /> I NQ ENvif? 6 <br /> O Z PE ONM f <br /> 1� ,— 15. Special Handling Instructions and Additional Information �c� q <br /> 00` 1V/CES tTH <br /> z <br /> w <br /> x <br /> J <br /> J )B. <br /> Q <br /> U <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of This consignment are fully and accurately described above by proper shippi,. <br /> name and are classified, packed. marked, and labeled, and are in all respects in proper condition for transport by highway according to applrcalL <br /> international and national government regulations. <br /> quantity large If I am a <br /> to g q y generator, I certify that I have a program in place to reduce the volume and toxicity of waste r disposal <br /> to the degree I ble <br /> 2 <br /> determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available <br /> O me which minimizes the present and future threat human health and the environment; OR, a I a small quantity generator. I have made a 90.. <br /> � faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. <br /> U <br /> wPrinted/TypedName Signature / r Month Day <br /> wRT 17. Transporter 1 Acknowleagniliment of Receipt of Materials <br /> Z A Printed/Type Name Sipneture / Month Day <br /> < N <br /> w1 <br /> u (' 1 <br /> O PO 15. Transporter 2 Acknowledgisifient of Receipt of Materials / <br /> T Printed/TY/ amp / Sipneture i Month Da <br /> UY <br /> E / r _ <br /> Z 19. Discrepancy Indicab n owe' / •%'i{-c.�'�. J <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 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 Signature Month Day <br /> V <br /> II <br /> DHS 5022 A(1/B7) INSTRUCTIONS ON THE BACK. <br /> EPA 870D-22 YELLOW: GENERATOR RETAINS <br /> (Rev..9-86)-efi) Previous editions are obsolete, <br />