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Department of Health Services
<br /> Toxic Substanoea Control Divialon
<br /> Sacramento,California
<br /> State of California—Health and%Wlare Agency '.
<br /> Form Approved OMB No.2450--0039(Expires e-30-t38) itch I Manifest g Pagli �p}ormation in!ha shaded areas-
<br /> Pieens rine or 1 e. Form des+ ned for use on effta ti2¢eneraloreerUSrEPA ID NO,', Documeflt No p} a d ie f10tYfeQtlir6[t by Federal falnr :4:
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<br /> WASTE MANIFEST A state anitsat � t iVumder.=` A r :l
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<br /> 3. Cienerator'e Name and Mailing Address e
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<br /> F�GhY' R`r.�7 e �7 l li State G9rNrstor6lO
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<br /> 5. Transporter 1 Company Name D 7ransPoA a pion!
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<br /> k12. Contamera 19 Total';,' nit t � W4tlfa No
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<br /> O t 1. US DO7 Description(including Proper SFiipping Name,Hazard Class:,and io Number)
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<br /> 16. Special ciaf Handling Instructions and Additional Information
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<br /> GENERATOR'S CERTIFICATION. I hereby declare that the contents,of this consignment are fully and accurately described above by proper ahlpping
<br /> name and are classified, packed, marked, and labeled, and are Well respects in proper condELon-tor transport by highway act rdmQ to appllCeble
<br /> _+ international and national government regulations. .. 'to reduce gqneratpd
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<br /> if I am a large quantity
<br /> ge ally practicable crtify tha and halal hevegae acteram in d the practicablemethodofatre trileetnd y storageof . or diaposaltcurrenlygavaiaable d
<br /> determined to.be generator, I have made a good
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<br /> I O me which minimizes the present and future threat to human health and the environment; OR. at ,a a small quantdy
<br /> U faith effort to minimize my waste generation and select the beat waste manepement method that is evadable to me and that I can affgrd.
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<br /> PrintedlTyped Name
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<br /> 17. Transporter 1 Acknowledgement of Receipt of Materials MoOth pay; Year
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<br /> O 18. Transporter 2 Acknowledgement or Receipt of Materials t s fulonih pay
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<br />} i 20. Facility Owner or Operator Certitiealion ofAreceipt of nexerdeua materials covered by this manifest except as nofedlin Item 19. .7. pay 'year
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<br /> DHS e022 A(5�B7) INSTRUCTIONS ON THE BACK "
<br /> YELLOW: GENERATOR RETAINS t ��
<br /> EPA 8700--22 s
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<br /> (Fav "e) Previous editions are obsolete
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