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<br /> — Slate of California—health and Welfare Agency Department of HI Servieoe
<br /> Toxic Substances Control Dlvlalon
<br /> Form Approved OMB No.2060-0039(Expires 9.30.88) Sacramento,California,t.',F.
<br /> Please print at type. Form designed for use on efffe 12- itch t awrifer
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<br /> UNIFORM HAZARDOUS 1. Generator'a UB EPA ID Ha. Manifest t a.Paget `�Informatiort in the shaded areae `
<br /> A/ pocument No. w ,pf ? )g not required by Feldera'I law
<br /> WASTE MANIFEST i- ,�` / :`
<br /> 3. Gene tor's Nem�sand Mailing Address A S f nif It urn
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<br /> 4r Generator's Phone t'f ('- �'r "
<br /> ,0 5. Transporter 1 Campany Name w. B. US EPA ID Number C "State Trans oAer's ID
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<br /> 9. Designated Facility Name and Site Address A10. US EPA ID Number Q State Faoilhy
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<br /> 16. Special Handling Instructions and Additional In/formation
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<br /> U GENERATOR'S CERTIFICATION: I herebydeclare that the contents of this consignment are full and accurate) described above b
<br /> fd Y Y Y Proper shipping
<br /> name and are classified, packed, marked, and labeled, and are in'811'rospects'in proper condilion'for transport by.highway according to applicable
<br /> tL international and national government regulations,
<br /> If I am a large quantity generator, I certify that l have a program in place to reduce the volume and toxicity`o�f waste generated to the degreel have
<br /> O determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to
<br /> me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator.1 have made a good
<br /> V faith effort to minimize my waste generation and select the best wast i nagement method that is available to me and that f can'afford *..
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<br /> ' W Printed/Typed Name
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<br /> R 17. Transporter t Acknowledgement of Receipt of Materiels �s s
<br /> Z A Prince /T ed Name 3i Hato e t �r
<br /> N _ . g > Month. as Year
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<br /> O 1 . Trs sporter 2 Acknowledgement of Raceipt of Miter)als Y a t' s
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<br /> Printed/Typed Name :-,
<br />€- a T. Signature
<br /> L) E Month 17ay Year
<br /> 19. Discrepancy indication Space -
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<br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted,In Flom 79
<br /> T. Printed/Typed Name Signature a r a R
<br /> Y `�s , -4. Manfh 'Day Year'.
<br /> DHS 8022 A(1 87)
<br /> EPA 8700-22 �{ cx INSTRUCTIONS Olt THE BACK t
<br /> (Rev.9-86) Previous editions are obsolete. YELLOW. GENERATOR RETAINS u. Fr �, ? " e•
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