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Depertrnenl cl Hsnl:h Sarvices <br /> Sae Instructions on Rank of Page 6 Tdxir.Subalancon Control oivinE,n <br /> State of California—Hoalih and wolloro Agency <br /> - ;.ind Front of PSC©7 Sacramento,California <br /> Form Approved OMB No.2050-0039(Ex P"naewdlar). - <br /> please print ar type. Form designed for use on all(12•pllch fyp Manileal 2.Page 1 Information in the shaded aroas <br /> 1.Generalci a US EPA 10 No. Document No. <br /> UNEF�RM HAZARDOl1S t of is not roqulred by Fecaral law. <br /> WASTEMANIFEST r, r ^ n <br /> � A Stara Man lost Doc*omen!Hufmr�ber <br /> .... 3.G.aeralor'a Name and IAaiGng Address <br /> i i.:y� r2(7i'ER i i ES 703 titan( S"RF-Fr B. stare 6en.raler■ID" <br /> SAS FRA'k.ISCO, CA 9--J i <br /> 4.Generator's Phone t ry)^ _ ';7 i C.SIela Tranaporter'a ID Jr,. L,! <br /> –, g, US EPA ID Number _ `� <br /> o <br /> .Tranaporter 1 Company Name D,Tranaporl Phone - <br /> T t <br /> r". t rNt- r`k` B US EPA t0 Number E.Stale Tr■nsporter'Ir <br /> m7.Trenaportar 2 Company Name I F.Transpodoelt Rhona <br /> Otp, US EPR IG NumLar G.Slate Facitffy'a H3 <br /> �_ g.Oealgnated Facility Nnme and Site Address <br /> ER ICK5(7N f?YC. w Faa1g1Y a Pneaa <br /> '.'r'y.R_R 13U.D y <br /> a� R].CEL'MiiU, Ct1 9�Jt3t I 1 <br /> `12.Cants inane 19.Total 14• <br /> Quantity Unl1 Waste Na <br /> };azard Cleea,and ID Numbed No. Typo wllvol <br /> U 11.US DOT Deaarlptiaa(Including proper Shipping Kama, Sia[a - <br /> _0 7 tL r1 <br /> a i.:' Jul.�.' '" <br /> iy. <br /> s:st;_ Ems ty ESar.�t d:5'.1� I. s } C 'r' EPA/M f �5 d f3 GAi. <br /> –'s = G - stale. a t = <br /> N v <br /> . E b. � EpA/O1her. <br /> R <br /> ci - <br /> m T r Stale <br /> O- <br /> ,. R <br /> ' c�•y — 57n1 r <br /> d. aPs/ot_tsaUj <br /> r_ yr <br /> U Ki-Handling.Or.destor:WeatesUetedrdrave <br /> a r <br /> J Addrtional osacnptlons for Malerfale Llated Above h 1 - �; <br /> n., panty `4r@51$$ of I tat)3 c d "" <br /> t: <br /> -, Yt <br /> 4 ' <br /> f .L s <br /> d <br /> 0 0 15 Special HandbnqM smclions and Addillonel Inlormallan <br /> – yob �lit3f i�Uitl 'Jf.i'_.:_, Of Iy:lftlCilSi- <br /> c� ilat ar.1 "Ias�=s nI.— wartia �roarl: u�d ryrou ld se�aai,3 Gatrris. <br /> Alrray3 wear h4 <br /> G 18. nment are fully and accurately described above by proper shipping name <br /> e U <br /> GENERATOR'S CERTIFICATION: I hereby declare That the contorts al Ihia conr c <br /> and are classified,packed,marked.and labeled,and are in all rrapeeis In proper condition ran irnnsport by Idphway according to appbcahle frtlarnel ane an <br /> national govatnment regulations.c. or disposal currently available to me which minimizes the <br /> V7 If 1 em a leve froalHe generator.I cer111Y 1he1 l have c progrtm In plata fo reduce the volume end taxicily of waste generated fa the degree I have de t'z.a++ <br /> a to be scononlically PreetiCabte and that l have selected the nraclicable method of treatment,storage. P <br /> O present and future t:real to human health and the onvironmern:OR,If I am a small quantity gannrefar,I have made a good faith effort to minimize my wants <br /> y generation and select the beat waste management method that r.available to mo and Ihal t can rd. Moifh Do Year I <br /> U � S?gnalu•e:i <br /> Printed/Typed Name: <br /> W <br /> / Year <br /> T 17.Tire sport <br /> 1 AcknowSadpemenl of Receipt of Materials r I —�^';• /,{aafh Day <br /> UJIR Signature <br /> A Printadl TYpod Name ! <br /> i 1 P1 l !t•1 r_,fps 1 __J <br /> O 1B.Tfanaporkef 2 cknawledgomen!al Receipt cl Melerfale Afnnlh Day Yenr <br /> Signstwe <br /> ) T Pelnted/Typed Name 1 <br /> E <br /> 19.Discrepancy IndicaGOIN Spare <br /> F <br /> A <br /> C <br /> 1 <br /> e L9. <br /> N..tnlh nay Yaer <br /> I 20.Facility owner of Operator Cafil: cation nl script OI hezardcus materials covurer by cels manileal oxcap!0e noted in Ilam 1 <br /> „ $Ignnlufr, I I <br /> '+. •r prinlediTyped Name <br /> Do Not Vy'rif�Below This Lina <br /> DHS 8022 A - - <br /> EPA U704-22 - YELLOW: GENfi6iATOR M"TAINS <br /> (Rav,B.B9)pravluus editions are obsolete, <br />