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State of California—Health and Welfare AgencyDepartment of Health Services <br /> Toxic Substances Control Division <br /> Sacramento,California <br /> Pleats print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST - % .� ",r; — l Docume t1la <br /> N of w.not required by Federal <br /> 3. Generators Name andMailin ddress / AStateManlfet umentNumber <br /> > " �_s ,-e ,-.rte 8 4 E <br /> estateGBnerator <br /> a. Generator's Phone <br /> 5. Transporter 1 Company Name 6. US EPA ID Number OStat@"�T' �aas�1'br •: <br /> L ji>dt(CI e -l) , ;S. ,. ' . D.TransPortera;P�1,C1118 <br /> 7. Transporter 2 Company Name B. US EPA ID Number FAtalBFTtanBpor(9(e .a^ <br /> F:1t'a sPprters PhiJit@��4"r"��='�#"� p" <br /> 9 Designated Facility Name and Site Add ass 10. US EPA ID Number if8gility a 1D i1 <br /> 7;C_- n <br /> 0 �X 33r� ty s..Phone- <br /> to <br /> fro' _ <br /> / 12.Containers 13. 14 <br /> Total Unit11.US DOT Description(Including Proper Shipping Name, Hazard Class,and ID Number) wast 'N <br /> No. Type Quantity t/vo <br /> 0 <br /> R <br /> 5 A b. <br /> O <br /> C. <br /> .dte:aF <br /> �t <br /> d. <br /> 1 <br /> � i<CIO iatedatd`lett YR nngLodetill", sten <br /> CV3 `e M <br /> /"f1 y f .l'.ln ,4 �'� 4s.• b �� � YJ 4 �� - <br /> co <br /> qcj- 15. Special Handling Instructions and Additional Information <br /> 00 <br /> 16.GENERATOR'S CERTIFICATION:I 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 a or�In�g to�applicabp,to ationLnation— �oer�ental regulations. <br /> TO- <br /> I Date <br /> Pri dlT ped NamA Signallilite Month Day Year <br /> 1 17.Transporter 1 AcknowledgemenVof Receipt of Materials Date <br /> R <br /> Printed/Typed Name Sig r Month De Year <br /> o 18.Transporter 2 Acknowledgement of Receipt of Materia Date <br /> T Printed/Typed Name _ Signature Month Day Year <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 20.Facilityy Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted In <br /> i t Item 19. Dale <br /> 1 <br /> Y Pr ln /Ty d Nam slgnatur Month Day Year <br /> rPO <br /> 3112 <br /> DHS 8022 A(11184) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS 04 89M <br /> EPA 8700-22 To: P.O. Box 3000, Sacromento CA 95812 - <br />