Laserfiche WebLink
State of California—Health and Welfare Agency Department of Health Services <br /> Form Approved OMD No.2050039(Expires 930-88) Toxic Substances Control Division <br /> Pbese print or type. Form designed for me on elife I'lzignich typearmeil, Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest 2 Papa 1 <br /> UNIFORM HAZARDOUS Docgment No. Information in the shaded areas <br /> WASTE MANIFEST r/ pf is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> V- - l 87851151 <br /> Uj r' C"TO� D. State Generator's ID <br /> d� <br /> 4. General .� one( '1 ) <br /> eQj 5. Transporter 1 Company Name ... US EPA ID Number C. Slate Transporter's ID <br /> D. Transporter's Phone ��- <br /> O1n1 Transporter 2 C pent'Name 8. US EPA ID Number E. State Transporter'.ID <br /> m <br /> OO F. Transpodeis Phone <br /> 0 <br /> 9. pesignated Facility Name and Site Address 10. US EPA ID Number G, State Facility's ID <br /> U L� Gyl /y4/1'i lz H"SH. Facility's Phone <br /> a { / <br /> 9L'4 <br /> Q 12. Containers 13. Total 14, I. <br /> OLL 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Ouentity Unit Waste No. <br /> No. Type Il <br /> EM�afy oi� rp y/e �se <br /> U e. State <br /> C <br /> E CA/..t/��6�i9/�� L'., f1�/�- /� 7U EPA/Other <br /> 3 N <br /> E D. State <br /> ou R <br /> m <br /> m A 'EPA/Other <br /> T <br /> v R c. State <br /> 0 <br /> 0 <br /> m <br /> EPA/Other <br /> W d. State <br /> Z <br /> w <br /> U EPAIOther <br /> U.) <br /> m J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> afor <br /> �MAO�Jp'� (l1J/,Q t'Y(�(-n�i✓V c{ ''`3S e. b. <br /> c. d. <br /> z <br /> O <br /> r 15 Special Handling Instruct ons and Additional Information <br /> Z <br /> jai;; JU�� 01988 <br /> J <br /> < t. M 4 H j�(�,� <br /> O GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accd efely:� ,TAL H lipping <br /> name and are classified, packed, marked, and labeled, and are in all respects in proper condition for tran alh t applicable <br /> a <br /> international and national government regulations. <br /> m <br /> It I em fined to quantity generator, I certity that I have a program in place pr reduce the volume and toxicity o1 waste generated to the degree I have <br /> 2 determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available <br /> U me which minimizes the present and future three) to human h@alth and the environment; OR, if I em a small quantity generator. I have made a good <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 /> Z <br /> W Printed/Typed Name Signa x Month Day Year <br /> CEOW <br /> w T n <br /> raee iter I Acknowledgement of Receipt of Materials <br /> R <br /> Zd, A Printed/Typed Name Signa ^� Month Day Year <br /> N <br /> LL S / v I } f.. <br /> O P <br /> O 18. Transporter 2 Acknowled amen of Receipt of Material <br /> w <br /> m R Printed/Typed Name Signature Month Day Year <br /> Q T <br /> U E <br /> Z <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> G <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materiels covered by this manifest except as noted in Rem 19. <br /> T Printed/Typed Name signature - Month Day Year <br /> T 1 <br /> DHS 8022 A(1/87) Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS INSTRUCTIONS ON THE BACK <br /> 8700-22 <br /> (Re986) viTo: P.O, Box 4D0, Sacramento, CA 95802 <br /> (Rev.9088) Previous editions are obaolele. <br />