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Department of Health Services
<br /> Toxic Substances Control Division
<br /> Statr,ol California—Health and Welfare Agency Sacramento California
<br /> Form_Approved OMS No. 2050—W39(Expires 9-30.60)
<br /> Please Tint or 1 e. Form des' ned for use on elite f ' h',f ewrifer. �Iqa 1. 13enerator's US EPA IS]No. Manifest 2 (age 1 Intorllietion itsAhe BhUNIFORM HAZARDOUS '' Rocurnent Na. pf , :is not Cequirad by Fe
<br /> WASTE MANIFEST
<br /> A Stt}t manif�s nourrient Number
<br /> 3. Generator's Name and Mailing Addreae r
<br /> 5. Stolle Generali a,'
<br /> ID ;-
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<br /> 4. Generator's Phone( 1 r'. ':Z
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<br /> U$EPA If),Number' .
<br /> C, stets 7ranepprtat'e
<br /> Name
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<br /> Company Transporter ortar t Com a Y �
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<br /> 7. Traneporler 2 C pony Name E:',9fate TrsneprNtat'e
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<br /> Num er r
<br /> F: Tranaporter'e phone 1g a.
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<br /> B. Designated Facility Name and Site Address 10. US ERA ID Number 13 $�ete`Fepklity tl lQ f'r f; 1 M yrs d;`s 7 rs a r
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<br /> 12. Containers 13. Total,i 14.
<br /> 'Quantity Unit WaseN9 ` i
<br /> O 11. US DOT Description(Including Proper Shipping Name,Hazard Class and ID Number) a+ r ". WI!Va ;@�a..k,`'_'
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<br /> Z 1. Additional Qeecriptionls for Matedtila Lssted.Above{ � ?v v, ;> r iia , K Iisttdling Cogpe 3or Waet�s(Je;ed App
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<br /> 15. Special Handling Instructions and Additional Information
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<br /> V GENERATOR'S CERTIFICATION: I hereby deniers that the contents of Ihis•conaignment are fully and eccu�sFwyo,�c�i 6604K ,�y Pr Par Shipping
<br /> ,i name and are classified, packed, marked, and labele�4, and are_ in all respects,in proper conditionrtar transport by highway eccordm to appttca4len s Y
<br /> J international and national government regulations.
<br />{ m -'—If+am-a large quantity-generator,;1.certify that I have a program in place_to reduce the volume and toxicity of waste Venerated to the degree 1 have
<br /> ¢ determined to be economically practicable and that I have selected the-practicable method of freatment,.atoiage,-or disposal currently aVaileble to
<br /> 0 me which minimizes the present and future threat to human-health and the environment; OR, it I am..a small quantity generator, )have made a good +i
<br /> faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford i
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<br /> W Printed/Typed Name Signature 7/ r: +t e' Month 4 Day Year
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<br /> 17. Tra11 A4 4
<br /> nsporter 1 Acknowledgement of Receipt of MaterialsIjj
<br /> Z A printedlTyped Na Signet re Month Day 'Yaer
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<br /> O16: Transporter 2 Acknowledgement.o Receipt of Materials
<br /> R Signature Month Day Year. :}
<br /> T Prinied/TVped Name ; th
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<br /> 19. Discrepancy Indication Space I"
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<br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted In Item 19
<br /> T Signature '
<br /> PrinledlTYped Name g y :Month Day Year -µ
<br /> DHS 8022 A(1187) # INSTRUCTIONS.ON THE BACK
<br /> EPA e7oo-22 YELLOW. GENERATOR RETAINS E
<br /> (Rev.9•8a) previous-editions are obsolete.
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