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Department of Health Services <br /> state of Cpllforda—#iaallh and Welfare Agency Taxic Substances Ccmtol Division <br /> Form Apprevod Orde No.2666--4)D99(Expires 9-30-2 1) Secramenlo•California <br /> Pleas prim or type, (Farm designed for uaa ort ahra(12-pilch typ+wrhar)- Manifest 2.Pe9a 1 <br /> 1.Oanerstar's US EPA ID,No. Informatio�h. ded areas <br /> UNIFORM HAZARDOUS 0 � �1 y � � Document No. <br /> WASTE MANIFEST �+ of la not reqderal law. <br /> 9,Generator's Name antl mailing Addreso <br /> A.B1aSe Ifeal Document Number/beer+ ' <br /> �•�' S ry+� 1 <br /> �ITIP 1T'f1. /�� (� T/� - 8. 131+1acisnEralar4lD <br /> •n671S1E�e Yhdei 1� '!"�' I Y �A'e *5376 <br /> Trntlspor(pr'ar ID <br /> 6.Trsasparlar t Company Name <br /> 6. US EPA ID Number 17 is 1Lnj C.Slab r. <br /> D.TrenePal�r@ I'tpfiP' <br /> 8. US EPA 10 Number E.011it Tr4repprterl IP <br /> T.Ttansporier 2 Company Name Y <br /> Trfri"Were Priori , } <br /> 9.Designated Ficillly Name and Site Adtlreu <br /> 10. US EPA ID Number 0•sill!�sciiliy'7 67 <br /> Diff ILJiiillf.6OW, CA 9+WjEAa&aLft&U <br /> W.Canlalners3.Ouantlly Unt4• <br /> l Waste No. <br /> 1 4 all <br /> L US D07 Description(including proper Shipping Nama,Hazard Clsea•and ID Numbed No. Typo WvyVo' <br /> Stele <br /> a1(01 a CAt.IF0IriA ifUkTE�3 bi5' E Gl` .Y 10fRA 0 O 1 D T 0110101210_ <br /> Y EPAIan <br /> WIN <br /> E b. <br /> R EPA/O1 or <br /> A <br /> OBtala <br /> q R G. <br /> 98Y EPAf Omer <br /> Stale <br /> a d. <br /> EPA'0"" <br /> K Hf�4!!Ir1 1(orl4reetri u�igd Ahovo <br /> J.Add47wrFl R�Wtlplionaf fel Haled Ne 41atod A-or, - - ., a <br /> ptl.': INATED WITH. OI W a 6 C d <br /> is.Special Handlln9 Inatrucllons end Additional lnl0fmation <br /> Y RUILF M -,562 t�OGCI <br /> kEAR aMB, iS & PROTECTIVE EQUIPPeff <br /> 14. y proper ahl In name <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment aro lull and by highway <br /> described above by prop pP 4 <br /> Jand are claeaiBad,packed,marked,and labeled,and are in all respects In proper eonditioa for irensport by hiyhwey aecardin9 to epplicab'w international and <br /> national government regulations. <br /> the velums and toxicity of waste generated to the degree I have determ.no <br /> B I are■large quantity 9+nerator.I certify that I have a Program In place to reduce <br /> pr be sent and future I xeat to human health hand lheeenviirthe ronment•OR,Ile malhod of l arm a smalltquantity Generator,I have made argootd available <br /> effort to rn nimlze my waste nu <br /> 99neration and select the beet waste mansuame 11 melhod that Is available to me and that I can sitord. <br /> Sipnatur %� Month Day Year <br /> PrintadlTypad Name �:, ,.�...- <br /> 17.Transporter 1 Acknowledgement or Receipt m blaterleb Monfh bay Year <br /> 9 Slonature <br /> t�. N Printed Typed Name <br /> v $ <br /> F 18.Transporter 2 Acknowledgement o!BacHpt of Materials <br /> O Month Day Year <br /> R PrinledlTyped Nama Signalun �• <br /> T j 1 I <br /> i s ! <br /> 19.Discrepancy Indlcailon Spica All <br /> F <br /> A <br /> `. 2o.Facility Owner or Openter cartiticatlan or receipt al hazardous meledale.cav+red by this manHssl.aYcepl ea notal In Bim 19. <br /> Afonth �DaY Year. .._........ _._..... <br /> Y <br /> ' Prinlid+Typed Norte9ignelure <br /> ------------------- <br /> DHS 6022 A(f lee) Do Not Write Below This line <br /> EPA 8700—zz.- <br /> (Rev.9•56)Previous editions are cbsoli:M YELLOW: GENERATOR RETh; <br />