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aralearUalifornis---Healthand Welfare Agency <br /> ' FOrN Approved OMI?No.2050--0039(Expires 9-30.91) Department of Health Services <br /> Toxic Substances Control Division <br /> Please print or type. (Form designed for use on elite( 'ch typewrit r� Sacramento,California <br /> UNIFORM HAZARDOUS ' erator's US EPA ID No. Mani at NpoPage 1 <br /> Document No. �Int..O,-ation in the shaded areasWASTE MANIFEST of required by Federal law. <br /> 3. enerator's Name nd Mailing Address A. State Manifest Document Number <br /> relc4l;-� /e/-3 8 <br /> B. State Generator's ID <br /> a. Generator's Phone'-1 r } C <br /> 71 <br /> 4-ho, (`/0 ��j �r 4,J <br /> 5. Tra sp rter 1 Comp ny� ame 6. US EPA ID Number C. Sta a Transporter's ID <br /> ,� / 1 <br /> r y <br /> N — 'i D. Transporter's Phone <br /> m 7. Transporter 2 Company Name— <br /> US CPA-10'Number" E. State Transporter's tFr f <br /> 0 <br /> o 1 1 F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> I <br /> 0,4 1_ <br /> �+U <br /> H. Facility'APftna <br /> DO 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and iD Number) 12.Containers 13. Total 14. <br /> Quantity" Unit Waste No. <br /> ~J No. Type Wt/Vol <br /> ¢ a <br /> State <br /> r)2 Gid <br /> M E ( /�'' EPA/ hdr <br /> s E b. --7 <br /> of R State <br /> CO A <br /> °0 T EPA/Other <br /> N O <br /> State <br /> 0 <br /> C <br /> m <br /> EPA/Other <br /> LU d. <br /> H State <br /> Z <br /> Lu <br /> U CPA/Other <br /> 1n J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> O a. b, <br /> c- <br /> rn <br /> w <br /> d. <br /> Z <br /> O <br /> 15, Special Handling Instructions and Additional Information <br /> LArf i:: <br /> J i <br /> J <br /> U 18. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are lully and accurately described above by proper shipping name <br /> 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 /> QLnational government regulations. <br /> iZ If I am a large quantity generator.I certify that I have a program in place to reduce the volume end 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 /> U generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> Lu Printed/Typed Name r Signature ; Month Day Year <br /> cc <br /> LLJ <br /> Lu T 17. ransporter 1 Acknowledge •ent of Receipt of Materials <br /> R <br /> Z <br /> ¢ A Printed/Typed Name r Signature i Month Day Year, <br /> N r 1. r f 7 <br /> LLO S { r <br /> P <br /> w O 18. Transporter 2 Acknowledgeme of Receipt of Materials <br /> ¢ A Printed/Typed Name Signature Month Day Year <br /> U E <br /> Z R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I, <br /> L <br /> 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 ' <br /> •r1 „ Month Day Year I <br /> OHS 6022 A(1/88) D Not Write 'low Fhis f lne ` a <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. <br /> GREEN: HAULER RETAINS <br />