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fa+ayancY v g <br /> •-Form•A{ipvoved OMB No.2060-0039(Expires 9.30.9 1) <br /> Jee In3[fUCTIO�is('on 8~a(.�k of Pa 6 6 - Department of Health Services <br /> Ps9,R['iTf or typo. Form Designed for use on Nit.(12 h type erJ. and Front of Page--7 Toxic Substances Control Division <br /> Y, Sacramento.Cafifomia <br /> "UNIFORM HAZARDOUS 1•�eratct-a US EPA ID No. Manifest <br /> Pace , <br /> WASTE MANIFEST 0 nt No. Informetf0n in the ehedsd areas <br /> 3. Generator's Name and Mailing Address of is no requhed by Federal law. <br /> 04//K S;� �'17�4rQk F S�(•.. 3� A. State Manifest Document Number <br /> F,fiTV'yt�,eis� T+ FR axe s 3� a. ac t.Geitentdr e o <br /> 4. Generator's P903 <br /> hone <br /> L_ <br /> 0 6. Transporter 1 Company Name 8. US EPA ID Number <br /> C. State Trainportsem ID <br /> r <br /> D. Tnnaportwe Phone <br /> m 7. Transporter 2 Company Name <br /> 9. S EPA ID umbar E. State Tranapofter's ID <br /> F. Trollop <br /> orter's + <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number O. State FaMaprre A <br /> 6-i6Scw O/[ Go, <br /> �7S SFAo �/ $G Vv, <br /> FL Fa efMToaa <br /> f 7 .. <br /> nz S <br /> 0 11. US DOT Description(Including Proper Shipping 12. Containers 13. Total 1a.Shipping Neme,Hazard Class,and ID Number) Quantity Unit Waste NO. <br /> Q No. Type Wt/Vol <br /> Il,U G a^W�+ebdx/'S (�f�.l%� I./Q�//!� /vi 01 1 Stets <br />'JZ <br /> n� E �- �0 7 <br /> N EPA/OMst <br /> E b. <br /> r)8 A <br /> cP ``fie <br /> OD T - fi+�} k•`o I...,. EPAfO1Mt �'ti <br /> o R C. <br /> s <br /> Sate <br /> JAN 17 <br /> 1992 <br /> ¢ d <br /> Z PERMIT/SER\6 i_., st.�. t ; <br /> Z <br /> r. { <br /> W iPA/016K�, i <br /> Z J. Additional Descriptions for MateAeb Usted Ahore - <br /> ZO K.iNnNkq Codes far Wastes Listed Aboye; . <br /> �AJ/t16 /7 lUfl� (:l+A/�2 l+�//T�,l <br /> W U! <br /> b.W <br /> AC-r <AL 2IEc G��a r <br /> o d. <br /> 40 <br /> Q 16. Special Handling Instructions and Additional Information <br /> jWf <br /> U <br /> ,B. <br /> J GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully 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 /> tonational government regulations. <br /> If I am a large quantity generator,1 certify that I have aprogram <br /> 0 to be economically practicable and that I have selectedIn place to reduce the volume and storage, <br /> Dry of waste generated it the degree I have Me <br /> practicable I method of treatment,storage,or adisposal currency available to me which minimizesywasttin <br /> D- present and future threat to human health and the a echo that Is a if l am a emaN q that generator,I have made a pool faith effort to mMin,he my waste <br /> U i generation end seleel Me best waste management method that ls evs�ilsbls to Irte that 1 can afford. ,. n <br /> Z Printed/Typed TT � � Signatuw Month, Day year <br /> IF <br /> t5 'l;t! `pii+'` -�� %b. ry �.,. .. i Z <br /> -z _ y,�, <br /> WS. r t.. ti .,: :3 f,g :lit <br /> 'x1SlS"3 <br /> MT 17. Transporter 1 Acknowfoidgwyne—ni of Receipt of Me Isla <br /> R <br /> G A Printed/Typed Name SigrjOurel Month Day Year <br /> O g _ <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Mae als <br /> UR Printed/Typed Name SI Lure Month Day Year <br /> E <br /> Z <br /> 19. Discrepancy Indication Spaie <br /> F <br /> A <br /> C - <br /> I <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted M Mem 19. <br /> y Printed/Typed Name Signature i Month Day Year <br /> DHA 9022 A <br /> EPA e700-22 Do Not Write Below This line <br /> ' <br />(Rev.8.89)Previous edition are obsolete. <br /> Yellow: TSDF SENDS;iHIS COPY TO GENERATOR WITHIN 's A'T; <br />