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orateatCalifornia--Healthand Welfare Agency
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<br /> Form Approved OMB No.2050-0039(Expires 9-30-a I) tIOhS On Back Of Page 6 s' Department of Haeflh SeryFe:
<br /> and Front ta" cgs 7 Toxic Substances Control Divf>�lor
<br /> Please print or type.: Form designed for use one t2 pitch typewriter. gactamanto,CalhRj i+
<br /> UNIFORM HAZARDOUS 1, Generator's US EPA ID No. Manifest P 2. Page 1 lnformetion"In the shaded ar a
<br /> WASTE" MANIFEST
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<br /> nof,requiret py Federal haw` `
<br /> 3 Generator a Nameand Marling Address
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<br /> 4. Generator's Phone
<br /> S. Transporter 1 Company Name 8. US EPA ID,.Number t; glale Trartspprler's fD x
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<br /> m 9. Designated Facility Name and Site Address
<br /> 10. US EPA 1D Number
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<br /> 11. US DOT Deacrfptiori(Including Proper Shipping Name,Hazard Class,and ID Number) Containers 13. Total
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<br /> Special Handling Inatructtona and Additlonal Information I
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<br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by propefehipping�ams.;
<br /> � and are classified,packed,marked,and labeled,and are in all respects In proper condition for�transpori by highway according to applicable fnternatfanaf and
<br /> national government regulations. s k ; y - J
<br /> If I am a"large quantity generator.I certify that l have a program In place to reduce the volume and toxicity of waste generated to the degree'hsve:datermine�„�
<br /> q ao be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me whish minimizes the:
<br /> } present and future threat to human health and the environment;OR,It I aril a small quantity generator,I have made a good faith effort 19 minimize mX cele ��
<br /> U generation and select the best waste management method that is available tomeand that I can afford.`
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<br /> W T 117:N,Tranaporter 1 Acknowledgement of Receipt of Materials
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<br /> A Pr€Jnjt(SId! ped Name f fp1 ��} p” �! Signaturre ry q f i,+ ��} i6fonth ay Yea
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<br /> �� ; ig. T�aneporter 2 Acknowledgement al Receipt of Materials l :I t �� a
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<br /> I 20. Facility Owner or Operator Certlflcation pf receipt of hazardous materials covered by this manifes x
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<br /> Y s ed in Item 19.
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<br /> y PrintedlTypedName Signature �' ,MonttiAait�XYee
<br /> DHS$022 A
<br /> Do Not Write Below This Line F ` ' �s'�, R." >
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<br /> 8700-2 s.. ,.� .
<br /> (Rev.8 69).Pravloua editions are obsolete.
<br /> YELLOW3;'GENERAT0RRETAINS
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