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ORION! <br /> Stets o1 rove OKf Neelth and warfare xpency � <br /> Form Approved OLTB No.2058—pg39(Expires 9-30-91) Department or Health Services <br /> Pypo. (Form dea7pned for arae on stria(f2•pllch typewriter). <br /> Plea Beae Print or ToxicBubelances Control Division <br /> ' <br /> UNIFORM HAZARDOUS I. Generator's US EPA ID No. Manifest 2. Pape i <br /> Sacramenlo,California <br /> - <br /> WASTE MANIFEST Document Na.. Information In the shaded gross <br /> 3. Generator's Name and Wrilinp Addreas of is not•squired by Federal law, <br /> --=`1 sris MIT aup A. State Manfleat Document Number <br /> 275 Gran tIIne F,Da g <br /> '�racY kA 95378 f 9. stnls[Tenerator'a <br /> +• snare oda one{ <br /> w 5.TFanaporter 1 Company Name 8. USEPA ID Number <br /> r. G.State Tranaporter's lD - <br /> Ij 1 ) $ V Ct?CY <br /> I1 D.Trenepo-- Phone <br /> m 7. Transporter 2 Company Name 8 <br /> U EAI um er E.91s1e Transportar'a 10 <br /> - Tranaporter'a Phone <br /> g. Designated Facility Nene and Site Addressto. F. <br /> US cPA!p Number <br /> H S H S i l p s:ry I ce UJITt>at ly G.Stale Fa—fir'.tD <br /> SSU 220 Uinta basin Street <br /> �¢ Snn Francisco, GA 94697 H.Focal iy a ho <br /> S <br /> LL T 1. US DOT Description(Including Proper Shipping Name,Hazard Class,and to Number) 12• Containers .Tots <br /> V a, <br /> No. Type 4santity. Until '•Was!■No. <br /> wl/Val <br /> a0 E �S i� YIi 5M OIL TQC � �.�(: Blata <br /> N (CAL I RIM41 A UII_Y JEjAATT 7 X 3 Q . i' Par <br /> E 6. <br /> a R <br /> A Mete - <br /> m T <br /> R c, EPAIC"w <br /> Slue <br /> of. ------------ <br /> w state ' <br /> v1 f EPA/Other <br /> J. ddili9nal 0.aacrfptfone for Maieriala Gated Above <br /> K Wndling Codes for Wallas III Above <br /> tom» Q1f 500 gal ton -tank -last cont I�. <br /> flank Inert�cl wl tti dry lte' for transport. stm at t a <br /> 4 C d.: <br /> O r " <br /> aF - IS. Special Handling Inelructrone and Addlllonel Intormalion - - <br /> Z - <br /> t''- i4 iiDPK1tA'Fk t'F4} Wr111E CIMIR4; /4) RISPI RATI;. <br /> to. <br /> a.i GERERATOR'S CERTIFICATION: 1 hereby declare that The contenfe Of this conatgnment are fully and eccuralely described'above by proper shipping name <br /> and are cleaned.Packed,marked,and lebeiad,and are in all respects in proper condition for tranaporl by highway according to epplkable International and <br /> W national government regulations. <br /> p; H I am a large quantity generator,I earthy that I have a program In piece to reduce the volume and toxicity of waste generated to the degree I have determined <br /> t )O to be aconomleally Practicable and that 1 have selected the practicable method of treatment,storage,of disposal currently available tome whish minimizes iM <br /> present and future threat to human health and the eevironmenf;OR,N I am a small quangt.generator,1 have made a good OvAl effort}o minimize <br /> 2 generation and select the beat Waal*management method that It available to me and th F can afford. rfaith my waste <br /> W Prirdecl ed Name - <br /> r Signature 0 yp p <br /> LU <br /> fj Mbnfh 3te1 Yaar <br /> W IT:Transporter 1 Ac knowledge manf of Recall of Materials , <br /> A Panted/Typed flame <br /> -- O ...;..p... _.......(, 1:. �1..VAI ....:.__ .. ..----. _.__. signet <br /> . ....... ........... ...._._..-_.... ......j..- --....... ..........--. .Afonth .....Day Year <br /> w O 18.Transporter 2 Acknowledgement of Receipt of MaierialaIn <br /> U T Prhfted/Tlpad Name Signature <br /> Z £ Maefh Day Year <br /> 19,Dlaerepancy indication Space - -- <br /> F <br /> C <br /> t <br /> T 20,.Faeillly Owner or Op <br /> eralcr Card➢Ication of receipt of hazardous met erlste covered by Thte manliest except rte noted In Nam 19. <br /> Y PrinfsdlTYPetl Name <br /> Signature <br /> All Day Year <br /> vB 8022 A(11 18a) <br /> rA 8700--22DoNot Write Below This Line <br /> ev.9.88)Previous edlllaaa are obsolete. <br /> YELLOW: GENERATOR RETAINS <br />