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Department of Health Servlc
<br /> State of California—Health and Welfare AgencyToxic Substenoes Control Alvis
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<br /> Form Approved OMS No.2060-0039(Expires�88) 80cramsMo catltoi
<br /> Please rint or iyps. Form deal nod lot use an elite f2• itch f ewrlter. Manifest 2 Fara 1„ - `'
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<br /> UNIFORM HAZARDOUS 1• Uenerator'a US EPA ID No.' information m t#ie shadt3d area
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<br /> WASTE MANIFEST ' '� ' 6�
<br /> 3. Generator's Name and Melling Address r A St;1R Matlifri>34 Dpdiertent Numb9t +X11 u4yj' A
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<br /> O n Name,Hazard Class and ID Number) fi# OuanlitY 11n11 'f 1Na8Pe No' +
<br /> LL 11. US DOT ileaeription(Inctudinp Proper Shipp' g rvo Type Wtl.Vo k(rc>
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<br /> U GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping=
<br /> r'sriahYB end are classified, packed, marked, and lebeted, and are in all respects in,proper condition for trogsport dy:highway according to.appk�capfe
<br /> ;a international and national government regulations. + 3.
<br /> rn It i am a'large quantity generator,I certify that t have a•program in-piace to reduce thea volume end toxicity of-waste generated to the degree t have
<br /> ¢ determined,to.ge' conomically practicable and that I have selected the practicable method.of treatment, storage, or disposal currently available
<br /> y8 1 i,me whicli'f5tiirrinlizos the present and-future threat to human health and the environment; OR, if! am a small quantity generator, I-have made,
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<br /> management method that is_availabls to.me,ap-d that I can,afford "
<br /> - � Y faith ettalrt to minimize my waste generation and select the bast,wsste manse, }
<br /> -r iC7a Printed ITyp dN Signature ,j
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<br /> 17 Tran rter 1 Ac nowledgement of Receipt of Materials ¢ " I'
<br /> Z I.R. Pilntedl7yped Name - S4(Joatu r .{ Manfh .'Day r3 Yei
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<br /> O O 1e. eneporter 2 Acknow'edge enf t Receipt of Materials
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<br /> Q T Printedl.TYped Name 9lgnature ' 4 ' a Y s {' _r ,.fNgAfh -Aqy Y,er
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<br /> .19. Discrepancy Indication Space
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<br /> Ir 20. Facility Owner or Operator Certification of receipt of htizardous materials covered by this manifest except as notedJn Item 1B , 3r'
<br /> T Printod!'Typed Name ��f j 5iyneture l g �� " Month 'CeY Yer
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<br /> DHS 8022 A(1187) �hN!INSTAUCT]Dl+IS ON THE BACK
<br /> PA tsroo-zs )'EiIOW: CENE
<br /> EPA RETAINS r • Y,;
<br /> (RAV.8-88) Previous editions are obsolete
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