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State of Celifomie—Health and`9eltere Agency Department of Health Sernces <br /> Form Approved OMS No.206020039(Expires 9.30.88; Toxic Substances Control Division <br /> Please print or type. (Form designed for use on elite(1fWtch typewriter). Instructions on the yuck Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> 'WASTE MANIFEST Document No. <br /> of is not required by Federal law. <br /> 3. Generator's Name and Mailing Addreea A.lists Mitnifest Document Number <br /> 88026108 <br /> Dept of Military ONS f24B. State Generator's ID <br /> a. GJ*XQ *6.A"3M Maya StOOktCM, G. 95206 111111111111 <br /> 6. Transporter 1 Comps me 91sal 8. US EPA ID Number C. State Transporter's ID <br /> D. Transporter's Phone g S52 <br /> N <br /> 7. Tr C e.I LCI U A m r Ur 4 Lf 0 E. Stets Transporter's ID <br /> F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> 00 lefimary Services <br /> H. Facility's Phone <br /> QS 13331 North Highway 33 <br /> 95366 2o einers 1 eTxilill litleMe 1.' <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Claes.and ID Number) Quantity Unit Waste No. <br /> No. Type <br /> Wt/vol <br /> U a, Stets <br /> Z E Calif. Sagtglated Waste Only <br /> N EPA;Qthe:e.. <br /> w� v <br /> W E b. V A Stats <br /> R <br /> M2 A <br /> T EPA/Other <br /> v O <br /> V R C. State <br /> EPA/Clher <br /> w d. State <br /> EPA/Other <br /> W <br /> J. Additional Descriptions for Materiels Listed Above K. Hanging Codes for Wastes Listed Above <br /> a, It. <br /> M t+arte ai1/blter <br /> C. d. <br /> 16. Special Handling Instructions and Additional Information <br /> Z <br /> Mill 0141011 MQ % <br /> It to. <br /> J GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> -� 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 /> ynational government regulations. <br /> 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 determined <br /> to be economically practicable and that 1'have selected the practicable method of treatment,storage,or disposal currently available to me wMch minimizes the <br /> present and future threat to human health and the environment:OR,If I em a small quantity generator,I have made a good faith effort to minimize my waste <br /> U generation and select the beet waste management method that Is available-to ma and that I can afford. <br /> Z <br /> W Printed/Typed Name Signature Month Day Year <br /> [Q <br /> W 'r <br /> W R ra porter 1 Adknowled9emant of Receipt of Materials <br /> A. Printed/Typed Name Signature Month Day Year <br /> N <br /> O P <br /> W O /8. Transporter 2 Acknowledgement Receipt of Material <br /> < ' R Printed/Typed Name Signature Month Day Ywr <br /> U E <br /> 2 <br /> 19,.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> L <br /> 1 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 Nam. - Sipnatura Month Day Y <br /> n <br /> r� <br /> DHS 8022 A(�,Q' Do Not Wrl a ,'Wis Line.. GREEN: HAULER 9P_ NS <br /> EPA 8700-22 <br /> (Rev.9.86)Previous editions are obsolete. <br />