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Stale of California--Health and Welfare Agency [� 16-.tf[I lio 1, oo rr I 1, Oepertment of Health Services <br /> Form Apbrgved OMB Na.2050-0039(Expires 9-30- 1) 1� , �/'/q/•�'{ T is Substances Control Division <br /> Please print or type, (Form designed for use art elite(11 �1 nrfer). 4r�. + Sacramento,California <br /> (FOAM HAZARDOUS 1• era1.. s US EPA 10 No. Mantles <br /> t Paye 1 Information In the shaded areas <br /> WASTE MANIFEST A Q Doe ment N . <br /> of is not required by Federal law. <br /> 3. Ge rator's Name a M Ilino Add s� � p 5•�� A;.:t3tats Manifest Document, <br /> o um nt u be <br /> 8:;State Dabe►atoem 10. <br /> 4. Generator's Phone ) 3 <br /> S. Transporter i Company Na • a. U8 EPA ID Num er C�State,Transporter's ID <br /> ++//I . <br /> rl� f�/ U C'l�N N' . Transporter's Phone <br /> N <br /> n 7. Transporter 2 Company Name B. US EPA ID Nam of E;:8tata Tranaperter a 10 <br /> o F: TiNrlparteda Phone <br /> M <br /> 9. Designated Facility Name and Site Address 10. US EPA 10 Num ar Q: ale Faculty's ID <br /> J Erickson, Inc. <br /> IQ <br /> 255 Parr Blvd. K Faeluty' Phi <br /> a <br /> z :�.. <br /> 12_ Containers;-�}- � '13. Total � 14I.i ..'^ <br /> LL <br /> O 1 1. US DOT Description(Including Proper Shipping Name,Hazard Class,and 10 Numbo) `, Ouantity Unit '1`'"' VYde18'wo�.' <br /> j No. Type WitVol . <br /> a.W Ste Empty Storage Tank Amt A550d-�afed. state 512 <br /> Z G +p� <br /> F EPA/Other <br /> > Nv <br /> E b. <br /> R State <br /> A <br /> :n T EPA/Other - <br /> O a _ <br /> N <br /> 7 R <br /> C.� Il./i"_ i .state, <br /> n _ - EPAlOther <br /> u d- i` C Stele <br /> z _ <br /> -� EPA/Other <br /> LLS <br /> J. Additional Descriptions for Materialt Listed Above <br /> z .�Ie ,' " t' K'Handling Codes for Wastes Listed Above <br /> bi <br /> U Qty- .� Etiipty `Storage TaAW {s), <br /> Tann `{s}` haves lir'4zit33 1'I ° + d` . <br /> i Dry Ice per 1043 GA1:. Capac °ty.rl <br /> 15. Special Handling Instructions and Additional Information <br /> 4 <br /> = Keep away from sources of ignition. Always wea � hardhats when working around <br /> U.S.T. ' s <br /> J <br /> J <br /> 2 1E <br /> GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this conaignmanr are fully and accurately described above by proper shipping name <br /> and are classified,packed,marked,and labeled,and are in ail respects in proper conditl n for transport by highway ecdording to applicable international and <br /> n national government regulations_ <br />,r If I em a large quantity generator.I certify that I have a program in place to reduce the v me and toxicity of waste generated to the degree I have determined <br />•� to be economically practicable and that I have selected the practicable method of treatm M,storage,or disposal currentty available to me which minimizes.the <br /> present and future threat to human health and the environment;OR,111 am a smell quang nerstor,t a a a taflh effort to minimize my waste <br /> generation and select the beet waste management method that Is available to a and tilI n afford. <br /> IUPrimedrTyped NameSignatur - Month Day Year <br /> G <br /> `u T 17- Transporter t Acknowledgement of Receipt of Materials <br /> y R <br /> r Printed/ d NernLL1Ie� ri Sigaetu Month Day Year <br /> N <br /> S <br /> .j O 18. Transpo ar 2 Acknowledgement of Receipt of terials - <br /> C RPrinted/Typed Name <br /> T 3ignnlure Month Day Year <br /> E <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> L <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materials covet!dWlh anifeet except as noted in it 19. <br /> T <br /> Y tedITyped N e t Signal - Month Day Year <br /> y1 <br /> is 8c t r <br /> A aa> IL <br /> 700 <br />"A 8700-22Do Not Write Below This line <br /> Inv,9-88)Previous editions are obsolete. h;lr: 'D .;fr'}y till r}Pl' If-Z DON' "' f; IN 30 DAt' <br /> In. ao, �� 4rrlp, rI - 12 <br />