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nnOnncy <br /> See Instructions on [tack of Page 8 Department of Health vices; <br /> Form Approved type <br /> a No. ,designed <br /> (Expires elite :,ti._ -� Toxic Substances Control ''ision'- +. <br /> Pleesa am or and Front of Pao,`111 Print type. Form designed for use on elite(t 1 ,typewhter). d Sacramento,C " ip <br /> UNIFORM HAZARDOUS orator's US EPA 10 No, Manifest T Page 1 Information in the shaded meas t <br /> WASTE MANIFEST I Document No. <br /> of I is not required by Federal Ww. <br /> 3 Generators Name and Melling Address * A. State Manifest Doc um nt IN <br /> ar-7 - J0179724 <br /> 2735 F a. <br /> ' S. State GeneratoYa fD I <br /> :- 4. Generator's Phone( :jf.) U -; 7 <br /> 6. Tranaponer i Company Name 6. US EPA ID Number �C. State.Transporter-3 ID <br /> -..'. '" =J. T4E1i r• .�i?!T''�i Sr . , :.,a q v '7 71 ., D.JranaportermPhone <br /> T. Transporter 2 Company Name 6.. US EPA ID Number E. State Trenaponer'a ID S <br /> p =FI7SS9�F7i_<ii�r^..SC t $ (> F:.Transporters Phone <br /> m 9. Designated Facility Name and Site Address 10. US EPA ID NumberG. State Facifity'84D <br /> i <br /> U V [? FAST _ Vii'.( 7 _( ;17 •i H.-Facility's Phone, y <br /> : '12 Containers 13. Total 14. L- - <br /> 0(' 11. US DOT Description(Including Proper Shipping Name.Hazard Class,and 10 Number) Quantity Unit Wute No. 1 t <br /> ri. No. Type Wt/Vol <br /> aro,'4,73� i= a.'rI STeMr 'd wi n t <br />�'y`4. = G ' c✓'i t.[�)tiTf'liy .1.1.3:. <br /> ,- c - E � - r <br /> - N i S M+/�7- <br /> Y4 3 EItis <br /> l'r tv -R / '� } <br /> S A C EPA/War <br /> N Q <br /> a R c 3tata <br /> EPA.Other - <br /> w - d State - <br /> �- <br /> Z <br /> 0J Additional Descriptions for Materiels Listed Above K Handling Codes for Waste.Listed Above <br /> Z - ¢ems a b <br /> O <br /> 'd c d <br /> J VAA <br /> c e -. <br /> Z <br /> 15 Special Handling Instructions and Aodfitfapal Liformatkon f <br /> `[ <br /> J I <br /> VI <br /> GENERATOR'S CERTIFICATION: I hereby dxlare that the contents of this consignment are fully and accurately described above by proper shippia::ame <br /> and are classified,packed,marked,and laceled.and are in all respects in proper condition for transport by highway according to applicable international and <br /> 2 national government regulations. <br /> N <br /> 2 It 1 am a large quantity generator,I chatty:hat I have a program in place to reduce the volume and toxicity of waste generated it the degree I have determined <br /> O pr bent and future predicable and mei have selected the <br /> nm practicable method of treatment,storage,or disposal currently available to me which m y, ast the <br /> Y present and future threat to human health a�the environment:OR,it I em a small quantity generator.I have made a good faith effort to minimize my,waste <br /> O generation and select the best waste management method that is available to me and that I can afford. <br /> Z Pinted/Typed Name Signature Month Day.. Year <br /> WT 17. Transporter I Acknewledgerient of Receipt of Materials 5 <br /> R <br /> A Prip)ed/Typed Name , Jr. Signature Month Day. Year <br /> Z (/J <br /> IL v / db1Ui i� A r f„ - ?i / ,ru. i i'i. �t ..{ulr., 1 ✓lime i', J� i <br /> 18_ Transporter 2 Acknowledgement of ReaeIPT of Mateaals , <br /> D - - - - <br /> l <br /> < R - Month Day Year <br /> < T Printed Name Signature <br /> U E <br /> Z R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> L <br /> _ I _ 20. Facility Owner or Operator Certification of receipt 01 hazardous materiels covered by this menilest except as noted in Item 19. <br /> T <br /> Printed/Typed Name Signature - Month Oay Year <br /> 1 <br /> -DHS 8022A Do Not Write Below This Line f <br /> EPA 8700-22 <br /> (Rev.6 89)Previous editions are obsolete. <br /> ' YELLOW: GENERATOR RETAINS <br /> ' <br />