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T— :-- — — <br /> r State of Califorw—Health and Welfare Agency - Department of Health Services <br /> Form AWoveu4lAB No.2050-0039(Expires 9-30 - Toxic Substances Control Division <br /> Please print or type. (Form designed for use on eli typewriter). - Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest 2. Page 1 <br /> UNIFORM HAZARDOUS mormahou in the shaded areas <br /> WASTE MANIFEST Document No., <br /> 4 of is not requiretl by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> MS <br /> /17 ) B. State Generator's ID <br /> 4. Generator's Phone(" )/ J '�.�+-. r I~/ <br /> 5. ranaportar 1 Company Name - E ID <br /> 6 umber C. State Trenaporter's ID M J <br /> �2 C Fr r>J /� t S Se R U)c C R p o 16 6 7 D. Tranaporter'a Phone O G c <br /> N <br /> m7. Transporter 2 Company Name B. US EPA ID Number E. State Trenaporter's ID <br /> 0 F..Transporter's Phone <br /> 8 <br /> J 9. Designated dF litY Naamg and�te Andreas 10. US EPA ID Number G. State Facility's ID <br /> t� e/f( to < 101(3 I 7 <br /> U f 3 73?/ N' HAV 73 J H. Facility's Phone <br /> all <br /> RTIC IQ S 0Al c9 95 63 AO o8 3 / 6 ? r 810& g 7 _ <br /> V'r12. Cost ainers 13. Total 14. 1. <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Claes,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt/Vol <br /> ei� a. /P e A rP 90 t Stat! 3 <br /> R✓� C EPAf Ot <br /> N A} <br /> E b. State <br /> A <br /> 0 T EPA/Other <br /> V 0 <br /> < R 0. .� '.rl'.i(1 State <br /> CP <br /> EPA/Other <br /> wd. E\\iku1-r. 41'.'orl State <br /> Z <br /> w <br /> p EPA/Other <br /> w <br /> rn J. AdditionalDesPcri tion,for Mgteriels Listed Above K. Handling Codes for Wastes Listed Above <br /> Z (, /fir /U /q /ist <br /> 0 / a. b. <br /> jj/eSE'� J �11 <br /> C. d. <br /> 0 qs - <br /> Sad <br /> 0 <br /> � 15. Special Handling Instructions and Additional Information - <br /> Z <br /> Z <br /> �LouC <br /> J <br /> O 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 /> J 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 I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of wsafe generated to the degree I have determined <br /> 0 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,I have made a good faith effort to minimize my waste <br /> U generation and select the best waste management method that is available to me and that I can afford. <br /> w <br /> Printed/Typed Name Signature Month Day Year <br /> Z <br /> W <br /> w R 77 <br /> p efn Ackndwledgem o ecelpt of Materials <br /> A PTyped Na�ee � 0r <br /> gnetu a Ma n Day., e <br /> g <br /> P r' ;$e0 <br /> gl O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> UR Prin(ed/Typed Name Signature Month Day Year <br /> E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <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 <br /> y Printed/Typed Name Signature Month Day Year <br /> DHS 8022 A(1/88) Do Not Write Below This Line <br /> ERA988)Previous editions are obsolete.go-22 <br /> (Rev:9Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN.30 DAYS <br /> To: P.O. Box 400, Socramento, CA 95812-0400 <br />