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State of California—Health and Welfare Agency Department of Health Services <br /> Farm Approved OMB No.2050-0039(Expires 9-30-9 Toxic Substances Control Division <br /> Please print or type. (Form designed for use on elite( pitch typewriter). 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. q <br /> of snot re wired by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> /�'G�a-12 89802497 <br /> ���� Jll7�',�7�/� 8. State Generator's ID <br /> 4. Generators s FF one <br /> 7 <br /> L' 5. Transporter 1 Company Na 6. US EPA ID Number C. State Transporter's ID O <br /> F't' ^� '=E'S S@1^_ V l _ 17 <br /> D. Transporter's Phone ( L <br /> N _1. - <br /> 'n 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> CP <br /> 00 1 1 1 1 1 1 1 1 1 1 1 1 F. Transporter's Phone <br /> 0 <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> -' lici'1.nET'1CS SE 1^ivice (' 11 <br /> J H. Facility's Phone <br /> 13331 14. HWY. 33 <br /> .A¢ 12. Containers 13. Total <br /> 0 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> J No. Type Wt/Vol <br /> Q State <br /> G <br /> F- E EPA/Other <br /> N f <br /> E b. Stat <br /> iii R <br /> Co T l a `; 7'f' i 1 EPA/Other <br /> v 0 <br /> N R c. Vy State <br /> 0 <br /> 0 <br /> �.�t EPA/Other <br /> V <br /> Q <br /> ' <br /> Cr d. �i State <br /> F- <br /> w ENVpONAIENTAL f{EgLTH EPA/Other <br /> w <br /> PES MIT , 1 <br /> N J.,Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> 11.1 <br /> J <br /> Q <br /> Z <br /> O <br /> 15. Special Handling Instructions and Additional Information <br /> Z Wear Gloves Goggles & And Protective Clothing <br /> LU -LNCASE OF Et-tERGE.I4CY CALL (209) 892-6742 OR (209) ?-800-874-4444 <br /> J <br /> J <br /> ¢ 16. <br /> U <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J and are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> co national 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 /> 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,if I am a small quantity generator.I have made a good faith effort to minimize my waste <br /> >- <br /> U generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> W0 Printed/Typed Name Signature Month Day Year <br /> w _ <br /> wT 17. Transporter 1 Acknowledgement of Receipt of Mate Is <br /> Z R <br /> ¢ A Printed/Typed Name ignatur Month Day Year <br /> N <br /> LL S <br /> O P <br /> W O 18. a sporter 2 Acknowledgement of Re eipt of Materials <br /> ¢ R rioted/Typed Name Signature Month Day Year <br /> U E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <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 Name Signature Month Day Year <br /> DHS 8022 A(1/88) Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> To: P.O. Box 400, Sacramento, CA 95812-0100 <br />