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Department of Health Services <br /> Toxic Substances <br /> Control <br /> l Divi.ion <br /> ata,;a1 Californlo---Haa6h and Welfare Agency <br /> g tree 930 97) <br /> larnia <br /> Form Approved OMB No-21)60--00 (Expires @writer).' <br /> Placa print or Type• (Form dd$igned ror use on @lila(f2•ptich typ I Manii0*9 2.PaOa t Inlormetion <br /> I.GenralorIn the shaded crass <br /> e 's 8 P a• h a,- <br /> HAZARD <br /> (Y � of la not required by Federal taw. <br /> UNIFORM HAZA <br /> W STE MANIFEST V A. Stets Manifest DOC umon'Numq.) s�a <br /> 3.Qenorelor'e Hama end Mailing Addrir. i C: •.f <br /> /�pi(1��Ynj' T� CA ,a5 p.Big ifflanitrftore ID <br /> a.Genarzior's Phone( ) C. to Traha oA4i S 1p <br /> �lp� U1)E AID u ar S 1R P <br /> Q 6.Trona Drip__ar t Cemp!rr �}lU C R 9 0 5 7 0 o.Tf.pepart..re Phan. - <br /> ti LAG�1fi1�LiD1ll rr. � E.81st TnnepoAef'e ID <br /> N 8• US EPA 10 Number./e1 / ? <br /> 7.Transporter 2 Company Nam@ J s F.Tfanaportar a Ph-l;- <br /> r <br /> lata Fsci'sgy'a(G. . <br /> 8.Dsalpnated Facially Name and Slle Addreas 10. US EPA ID Number . <br /> SE OF CALIFORNIA PWIh T� L� n C q +� *� IT Paagitl# <br /> ( 9 4AI198UN6 520 6 �e�t1. 1. <br /> 12,Cantalners Quantity Unit waste No. <br /> Name,Hazard Clean,and ID Number) Na. Type wtival <br /> 11.US DOT Description(Including Proper Shipping N qq tt�� '•�' n r� p� �/ State <br /> a. OAL,IFOMIA WWTU) 1ASTL Vls�i WN RCRA <br /> 00 <br /> 1 D i Q 0 0 b O i <br /> State <br /> r E <br /> HE b, SPA10thet <br /> R <br /> A State <br /> T <br /> O <br /> c� R a. EPAIOthei <br /> exp§ Stets <br /> W d, EPAfOthar <br /> !� .. K:tlejdling Codas for Wasta#Listed Above <br /> _ a b. <br /> yY J.A•ydKlonal Pe#aRPtlon#Tor dale Lie e <br /> a . ;h QII. It GRA a d. <br /> 16.Special Handling Inatruotiona and Additional Intormallon <br /> PWILE 0 M <br /> > 6LM, MMLES & FWWIIIE <br /> nama <br /> GEHBRATOR'S Ci:RTIFICATION: I harady declare that lin li respecla In properico dalton for tri nspart by h[gb t ayeaceordl 9 to apscribed above plicahtarinlameilia al and <br /> and are classified,packed,marked,and labeled,and are in all resp <br /> national gavernmont regulations. <br /> N I am a large qusnlHy generator,l cantly that I have a program in place to reduce Ihv votumo and storage. <br /> o ly of os ate generated to the degree I have determined <br /> $ to bo economically usy ffy generalcticable end that 1 have so the practicable method of treatment,storage,or disposal currently faith ffe tome which minimizes the <br /> Y <br /> prevent <br /> neentian and aelehrct at to human want health <br /> management the method that s available to meam a lt and)hat generator, <br /> afford.have meds a flood faith effort to minimize my <br /> Month Day Year <br /> signalurs�'.r j <br /> Printa¢rTYped Haus <br /> r E � f I <br /> Mont <br /> W 17,•Transportsr t Ackaowladgement of Receipt o1 M@Udals signature h Day Year <br /> - <br /> R <br /> N PdntsdtTypad Nama <br /> I Matadata <br /> P - - Manlh pay Year . <br /> Q 78.Transporter 2 Anknvwladpemanl of Recelpl oSignature <br /> fl PriniedlTYped Namn <br /> to,Diserapanay Indication Space <br /> F <br /> _...... ._C..... <br /> e - - <br /> .. ... noted In Item 110- <br /> - Manlh... payYear <br /> ... ... _........._ .._...... _..._.__..... <br /> _ - 21).Facility Owner or Operator Cenlflcallon of receipt of hazardous maUrle3ligna'ut@d by ihla meniteat except a <br /> . �.y Prieled7Typed Name - - <br /> Do Not Write Below This Line <br /> DHS 8022A(t158) <br /> II <br /> EPA 8100-22 YELLOW-. GENERATOR RETAINS <br /> ! Gley.9.88)Pro vlous editions are obsolala. <br />