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"easr at or type. (Form designed to, Ido Toxic Substances Control Diws.., <br /> (12-piton rotor afUS Sacramento,Calllumu <br /> UNIFORM HAZARDOt t. GeneratoisUSEPA10No. z. Page, <br /> WASTE MANIFES7� r7 0o Information in the shaded areas <br /> J of is not required by Federal law. <br /> 3. Generator' N me and ailing Address <br /> (� �o fro�p.'M / A. Stale Manifest Document lumber <br /> / lll���l/ 23 <br /> I I/47d/- CZ1 'n-3,2Y B. Stele Generator's ID <br /> <. Generator's Phone /' <br /> 0 5. ranspprtar 1 Com <br /> 1'/'1 Nam J 8. US EPA ID Number C. State!ranspodei a to 7 61e <br /> i 1 I <br /> Tly O. Trenaporter'a Pho <br /> H 7. Transporter 2 Company Name <br /> m B. US EPA ID Number E. Slate Transporter-41D <br /> O ' ✓ �� Ck <br /> L(1) I�� Transporter's Pho <br /> m 9. Designated Facility Name nd Site Address '� — l <br /> j / 0. US EPA ID Number G. St a la Facility's ID <br /> a <br /> De/ne4no ��er�oc.n oZGoG A�u 77 ec�c� <br /> V H. Facility's Phone <br /> Z , <br /> O 11. US DOT Description(Including Proper Shipping 12. Containers 13. Total /4. 1. <br /> LL p piling Nema,Hazard Class,end ID Number) Quantity Unit Waste No. <br /> J Ng. Type W1/Vo <br /> 0 G aUticifs�e, ��'1 M (,S ��b�e LYS .r� Staff <br /> E <br /> � NEPA/Other <br /> 3 E b. VVVJ <br /> N R State <br /> A <br /> m T - EPA/Other <br /> a O <br /> N R k <br /> O <br /> O State <br /> 0 ,!. <br /> H d t <br /> EPA/Other <br /> Z <br /> V State <br /> W y <br /> U EPA/Other <br /> W <br /> = J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> b. <br /> Ny - <br /> O a C. d. <br /> a <br /> Oo <br /> Q15. Special Handling instructions and Additional Information <br /> COZ <br /> W <br /> Z <br /> F <br /> J <br /> Q 8. <br /> U GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> name and are classified, packed, marked. and labeled. and are in all respects in proper condition for transport by highway according to applicable <br /> J international and national government regulations. <br /> y If 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 <br /> IL determined to be economically practicable and that I have selected the practicable method of treatment, storage. or disposal currently available to <br /> 0 me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator. I have made a good <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. <br /> V <br /> Z Prints ype Nam Signature <br /> Month Day Year <br /> W <br /> z l I <br /> WR 17. Transporter 1 Acknowledg dent of Receipt of Materials <br /> A Prime ype Name Signature <br /> S (- \ e / g 4• / I month Day YeY <br /> LL <br /> O 0 18. Transporter 2 Acknowledgfipfnent of Receipt of Materials - <br /> UJ<In R Printed/Typed Name Signature <br /> T g Month Day Year <br /> 0 E <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> L20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manileat except as noted in Item 19. <br /> T Printed/Typed Nam. Signature <br /> y. 9 Month Day Year <br /> I I I I <br /> DHS 8022 A(I 187) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS INSTRUCTIONS ON THE BACK <br /> EPA 8700-22 <br /> (Rev.9-86) Previous editions are obsolete. T0: P.O. Box 3000, Sacramento, CA 95812 <br />