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ate of Callbrrua—Heallh and Welfare Agency <br /> r,Fornt'1q;-Proved OMB No.2050—oo39(Expires II) 21un <br /> O� r..Please print or type, (Form designed for use or.orfs 1f Department of Heb-nUNIFORM HAZARDOUS Ypewrifer) Toxic Substances Ccs-••„�,, <br /> t. Generator's US EPA 10 No. Sacramer•: Cain <br /> WASTE MANIFEST oManifest 2. Page t <br /> 0 4 8 6 2 8 0 7 7 cument No. Information in the shaded area s <br /> 3. Generator's Name and Mailing Address C' Q O of is not required by Federal la- <br /> S1' UON REMRD A. State Manifest Document Number <br /> 53 0 E. <br /> �NIARII��r Sri'RFET <br /> 4 ��”^■^^ e�u+� 95202 B. State Generators 10 <br /> n5. Transporter I Company Name <br /> 8. US EPA 10 Number <br /> r. C. Stats Tansporter'e ID <br /> T 7. Transporter 2 Company Name 6 6 3 9 2 D. Trensporter's Phone -- <br /> 8. US EPA ID Number 41 ) 235-1:93 <br /> E. State Transporter's ID <br /> 9. Designated Facility Name and Site Address F. Transporter-s Phone <br /> '1CKSON, INC. Io' US EPA 10 Number <br /> G. State Facility's ID <br /> 0 2555RARR B,vD, <br /> Z RIC�HVDM, CA. 94801 H Fectldy s Phone <br /> D009466392 (415) 235-1393 <br /> 1 I. US DOT Description(Including Proper Shipping Q Name.Hazard Class,and 10 Number) 12. Containers 13. Total 14. <br /> U a' No. Type Quantity Unit Waste % <br /> Wt/Vol <br /> Z G J✓, r��IPTY SM� TA1��, Slate <br /> 3 N CALIFORNIA REGULATM WAS-1E ONLY ---- <br /> R b. 0 0 1 T- P , _ n EPA/Otner <br /> �3a{ A 1 NONE <br /> T State <br /> O <br /> CY <br /> R c EPA/Other <br /> 8 <br /> Stale <br /> Cr <br /> d. t EPA/Other <br /> Z <br /> W <br /> U State <br /> W <br /> Z <br /> J. Additional Oescriptlons for Materials Listed Above EPA/Other <br /> a l f rl'Y varr-ZADED GASOLINE TANK NO. ,s z G K. Handling Codes for Wastes Listed Above <br /> `n i a. <br /> ICM WITH 15 LBS. DRY ICE PER 1,000 GAIICN b. <br /> CAPACITY 5_fr_EHD it JI-1-1-01 <br /> oC. <br /> d. <br /> Zi5. Special Handling Instructions and Additional Information <br /> W <br /> J <br /> J <br /> U <br /> 18. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above b <br /> y-� and are classified,packed marked and labeled,and are in all respect$in proper condition for transport by highway according to applicable inlarnationei a <br /> national government regulations. <br /> y proper shtpp,ng ria e <br /> cr ItIama g q <br /> O fo be economically practicable and that I have selected the practicable method of treatment,storage,or disposal current) <br /> r e uantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have deter- <br /> ure <br /> at <br /> Z generation and>_ Present and taelect thelbeat waatehealth <br /> enagemant method that is ave lableif I am ao mesmall <br /> and that Igenerator <br /> Can alford'have made a <br /> y available to me which mm�m�zes - <br /> good faith effort to minimize my as!, <br /> O Printed/Typed Name <br /> Signa ure <br /> L(` C..L Ya Y TU / Mpnrh Ca. �E <br /> W R 17. Transporter I Acknowledgement of Receipt of Materials <br /> Z <br /> < A Prinled/Typed Name , <br /> 5/l re _ <br /> O P Month Da, •�a <br /> W p 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> U) aln�4 i <br /> < R Printed/Typed Nams <br /> Zl <br /> Z E Signature <br /> Month Da, <br /> 19. Discrepancy Indication Space <br /> F <br /> A I <br /> C NIRONMEPv i AL HEAL) �l <br /> PERMFUSERVICES <br /> T 20. Faclkfy Owner or Operator Ge it cation of receipt of hazardous materials covered <br /> V Print T ped Name a manifest except a noted i m 19. <br /> Signatur <br /> Month Da. _ <br /> DHS 8022 A(1/88) <br /> EPA 8700--22 <br /> (Rev.9-88)Previous editions are obsolete. o N This Line <br />