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Stale of California--Healthand Welfare Agency Department of Health 9ervicee.
<br /> Form Approved OMB No.2050-0039(Expires 8-30.68) y >..Toklc Substances Control Division
<br /> Please print ort e. Form designed for use on efite f2• itch t ewrrifer. Sacramento,'Cellfomla
<br /> 1,"Generator's US EPA ID No. '_ Menifee! {`+2 Paga 1 �slrltpimpttnn;In the shaded arae$
<br /> UNIFORM HAZARDOUS Document No A 1e'ynr . }
<br /> WASTE MANIFEST 4 / { � °f Itt nal required by Fader.al law}
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<br /> 3. Generator's Name and Mailing Address A S t " It s1 urgent um 't ` 3 Ifv f ':
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<br /> 4. Generator's Phone( �. �f ' A!"
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<br /> 5. Transporter 1 Company Name, 8: t` US EPA ID Number C 8tnle T[afrsporleeo
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<br /> rar1," ^r r &UD Transporlere'Phony
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<br /> Lo 7. Transporter 2 Company Name
<br /> 8. U8ta1*,7re ,+ 'ADm „r
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<br /> 9. Designated Facility Name and Site Address "'10. US EPA ID iber G`tiStatts F It1f { ..,._g.-_
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<br /> O 12 Containers 13 Total -14 43c ( `ih
<br /> 11. US DOT Description Proper-Shipping,Na ne,Hazard,Class,'and-ID'Numbar) 4uantlly Und 1�Vaate No.
<br /> J l No. Type
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<br /> Z J"Additional Deacrlptlons}or M erials Listed Above r
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<br /> a15. Special Handling Instructions and Additional Information
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<br /> 113.
<br /> i U GENERATOR'S CERTIFICATION:.,I hereby declare that the contents of this consignment are fully and accurately described above"by"pr9j?I tli in
<br /> E - name=soli ari3'classifed,packed, ri:arked;;and labeled, anC.ara in all fespects in proper`Condition for Hansporl by highway.8ccordingrlb.`5pplpcabla�
<br /> international and national government regulations.
<br /> If!am a large quantity „ ! s
<br /> g q y generator, I certify that i have a program in place t-8—educe the volume and toxicity.of waste generated to the'degree I hav
<br /> determined to be economically practicable and that I have selected the practicable method of treatment, storage;-dr disposal currently.avaifabta at
<br /> I me which minimizes the present and future threat to human health and the environment; OR, if f am a smell uantil
<br /> q. y generatar,.l have'made a good ,
<br /> U faith effort to minimize my waste generation and select the best waste management method that is available tome and that Icon aftord
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<br /> W Printed/Typed Name k a
<br /> c7 { , Sfgnatu r r t t Mon!h Day ,Yearir
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<br /> W R 17. Transporter 1 Acknowledgement of Receipt of.IMaleriala
<br /> 4 A PrintedrTYped Name
<br /> Signal r�{ Month Day 'V Year
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<br /> W O 18.,Transporter 2 Acknowledgement of.Receipt of,',Materials - . s
<br /> ` d, R Printed/Typed Name Signature." +
<br />+S CJ E tt . Month, Day Year
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<br /> 19. Discrepancy Indication Space I rY
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<br /> T 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in item 19
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<br /> Y PrintedlTYPed Name Signature s E t� kr " Month -De v.Year
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<br /> DHS 8022 A(1/87)
<br /> EPA 87oo-22 p' INSTRUCTIONS ON THE SACK `
<br /> (Rev.9.86) Previous editions are obsolete. YELLOW: GENERATOR RETAINS .J <r
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