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State of California-Health and Welfare Agency See Instructions on Back of Page B Department of Health Ser%Ic+s <br /> Form Approved OMB No.2050-0039(Expires 9.30-91) Toxic Substances Control blv•r,inr <br /> Please print or and Front of Pay <br /> p type. Form designed for use on elite( :h typewriter). Sacramento,California <br /> UNIFORM HAZARDOUS aerator's US EPA ID No. Manifest Page 1 Information In the shaded areas <br /> WASTE MANIFEST C ° <br /> / of Is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State M nifest Docum t sr <br /> 64e" ¢ � 82387 <br /> 09. �r�V+�-T�� / ---F - * 8. state Generator's ID <br /> 4. Generator's Phone(d'(i) _ ! 'lam <br /> Q 5 Transporter 1 Company Name 8. US EPA IIDD 4uumber C. State Transporter's iD <br /> N l -ye- <br /> 7. Transporter 2 Company Name 8. US EPA ID Number It. State Transporter's ID <br /> g 1 1 1 1 1 1 1 1 1 1 1 1 F. Transjort e;Phone <br /> Co I <br /> 9. esignated Facility Name and Site Address 10. US EPA ID Number 13. state Facility's ID <br /> J Pi4xl s IE-A-161"(2041 444-xs � <br /> / /5 SU Ul N /�I v�'�� �'!�• K Facility's phone <br /> r�Z s -fir/C �S 37/ 5?0 <br /> c0¢ 12. Containers 13. Total 14, t. <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> MJ No. Type Wt/vol <br />/�m•y��il 0 a. Al /U •G- - state <br /> M� E I s/ EPA/OMsr -� <br /> N <br /> E V. D State <br /> C)N A gg <br /> Co T y EPA/Other <br /> v O <br /> 8 RC. JUN 2 3 1992 State <br /> EP /Other <br /> Lu d. State <br /> Z PERMIT/SERVICES <br /> W <br /> U EPA/Other <br /> J, dltlonat baaorlptions forMaterial*Listed Above atld inq Codes for VY woo Listed Above <br /> W <br /> ��r.,c.l ,il/i1/.�/�rf�i ) C. d. <br /> Q <br /> Z <br /> 0 15. Special Handling Instructions nd A dittonal Information <br /> Z use �-n�,vv ..�.¢-r-�� ,�% <br /> �4rr-7 o <br /> W <br /> J <br /> C� VZ 7 - 7z z <br /> Q 18. <br /> U <br /> J GENERATOR'S CERTIFICA N: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J and are classified,pecked,marked,and labeled,and are in all respects In proper condition for transport by highway according to applicable International and <br /> CL national government regulations. <br /> It I am a large quantity generator.I certify that I have a program In place to reduce the volume and toxicity of waste generated to the degree I have determine-1 <br /> Cr O to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> >- present and future threat to human health and the environment;OR,it I am a small quantity generator,I have made a good faith effort to minimize my waste <br /> U generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> Printed/Typed Name SI ature/ < Month <br /> Day Year <br /> W <br /> W T 17. ransporter 1 Acknowledgement of Receipt of Materiels <br /> R _ <br /> Q A Printed/Typed Name S netu ; j Month Day fear <br /> N j' / <br /> U- s - �y . <br /> P 18. Transporter 2 Acknowledgement of Receipt of Materiels <br /> Q R Printed/Typed Name Signature Month Day I eer I <br /> E <br /> ZFI_ <br /> 19. Discrepancy Indication Space <br /> I <br /> L <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 <br /> y Printed/Typed Name Signature Month Day Year <br /> �. <br /> DHS 8n22 A Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev a 89)Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> � t <br /> To: P.O. Box 400, Sacramento, CA 95812.0400 <br />