Laserfiche WebLink
• • Department of Health Services <br /> State of California—Health and Welfare Agency Toxic Substances Control Division <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) —In <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Page 1 In orot re ui the shaded areas <br /> �. Document o is not required by Federal <br /> WASTE MANIFEST •/) S Z�lt� of law. - <br /> 3. Generator's Name and Mailing Address A.State Manifest Document Number <br /> B.State Generator's ID <br /> 4. Generator's Phone t ,J 1 a r9 <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C.State:Transporters.1C <br /> r /,)(::�, -i 6 i/ . D:Transporter's <br /> 7. Transporter 2 Company Name 8. US EPA ID Number L.State I ranaporter a TD <br /> . . F.Transporteft Phone - - - - <br /> 9. Designated Fact l ity Name and Site Address 10. US EPA ID Number G.State Facility's ID <br /> Pit /rCo, `L om ✓ti/A ' t'C H.Facilltys hone <br /> �'D l3c'X 3 3 G G <br /> ')ArCC . . .75� ; Sias S3 SJ' <br /> 12.Containers 13. - <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total Unit Waste No. <br /> No. Type Quantity t1Vo <br /> G <br /> E a.. <br /> i.; <br /> R <br /> f-YI`t LL' �.1)c1•(/� L�'�F. fes. `)'LJ I�`S l�''C�-� C /�/—� Y':, t /�O <br /> <' T b. <br /> 0 <br /> R <br /> C. <br /> d. <br /> C\j K.Handling Codes for Waste9 Ltsted At11We <br /> CD J: Additionaf Descriptions for Materials Listed Above,_ „ <br /> 7. <br /> O) -a�j -$©•l-/,It�. i C_0U 1�1N/��-l.L� ' /L- : ?.� a <br /> N <br /> TAcD ✓`76> — <br /> 'V 15. Special Handling Instructions and Additional Information <br /> � A <br /> C: L� S - P� i j <br /> 16.GENERATOR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and are in all respects in proper condition <br /> for transport by highway according to applicable international and national governmental regulations. Date <br /> ArintedlTyped Name Signature in Dey Year <br /> Al < C. P. At9 ✓ tc 2 <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials V IDate <br /> R re Month Day Year <br /> A 1 ad'T ed Name <br /> N <br /> ? n C 7 <br /> 0 18.Transporter-2-Acknowledgemen of Recelpl 01 M'ateriale - Date <br /> RMonth De Year <br /> T Printed/Typed Name Signature y <br /> 61 <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> L 20.FacilitygOwner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> 1 Date <br /> y Print (Typed Name Slgnatur Month Day Year <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> DHS 8022 A(11184) 84 89eA r <br /> (EPA f1700-22)r To: P.O. Box 3000, Sacramento CA 95812 <br />