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�"' "•�'''. wnlo—Heor and Welfare Agency <br /> .oved OMB No'2050-0039(Expires 9-30.91) < Department of Health Services <br /> Ont Of See InshuCHOnS On baCte�page 6. Toxic Substances Contra Program <br /> type. Fath designed for use on elite(12-pitch fypewtlter) Sacramento,California <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest Document No. 2.Pape 1 Information In the shaded ureas <br /> WASTE MANIFEST I I 1 1 I 1 I 1 1 11 1 i/ 1 � at Is not required by Federal krw. <br /> 3.Generators Nome and Mailing Address Pr Slate MgrvfQs} Pit— <br /> STORE <br /> t STORE 1132 <br /> t ERTfBPfSE STREET Stare mer <br /> a Generators Pisa»( ) HONT CA 94537 <br /> 5.Transporter 1 Company Name 6.US EPA ID Number C Stale Franspote,Cs tD <br /> I 1 I I I I� I I 1 O Train"rter'a Ptxia» <br /> 7.Trane er 2 Company Name 8.US EPA ID Number £.State Faspottef!iD <br /> R G ON <br /> CIA_ <br /> 10 IO 1(0 702 f.Trot s ens Pltoiie <br /> 9.Designated Facility Name and Site Address 10.US EPA ID Number G Skits Foes <br /> N G Co. T�1 •! it.. IF TES <br /> SE PY�rj!s} BLVD A D 0 4 ? 2 6 0 T 0 2 11 FaGitYsPtorse :: g <br /> E UNIT 1 �' FJf <br /> 11.LIS DOT Description(Including Proper Shipping Name,Hazard Claa,ad ID Number) 12.Corrtorners 13 Total 14.UnitNO. T Quant' WtNoi 1 Waster Num... <br /> HAZAROWS •7y7titi E LI�M�•[1{ , W,O.S, <br /> C a. 710 V 0� State <br /> U G RM-ff <br /> d'Q E WATE1 WITH L S THAN IS GASGLINE) 1 i I I I I I <br /> P`z N <br /> �..�0 E a <br /> 3 S1late <br /> Got R <br /> P"= aider <br /> V-4g� R <br /> a co <br /> Srcte <br /> �! <br /> N <br /> �,."-- ta:Moferkak lsted Adove ndlmgf6des for Wosias listed A9ove <br /> 1 I t <br /> IC Ho <br /> SF <br /> Q <br /> �" 1� �fTAIWlEk LAS � b <br /> U 18.Special Horx ng Instructions and Additional IMOmration . <br /> w GLOVES, GOGGLES 6 APPROPRIATE PERSONAL PROTECTIVE EOUIPHENT EjqvG.-leT 31 <br /> z <br /> w <br /> EMERGENCY CONTACT- RICH GARL1011--$16.659-0404 <br /> c s <br /> J <br /> 16. GENERATORS CERTIFICATION: I hereby declare that the contents of this consignment are fully anre d accurately described above by proper shipping name and aclassified, <br /> zpacked,marked,and labeled,and ore In aAf)3spects In proper condition for transport by highway according to applicable IMemationd and national govenxnert nrgulatko <br /> ' Q If 1 am a large quontily generator.I certify that 1 have a program In place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> z economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which mkftizes the present and future <br /> A = threat to hurnon health and the erNkonment:OR.If 1 am a small quantity,generator,I have made a good faith effort to mini nine my waste generation and select the best waste <br /> rnvsogemert method that 6 walkable to me and that 1 can afford. <br /> J <br /> Q PrInted/Typed Name 5ig e 1 Month Day Year <br /> — tCC I In 1 <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> 0 R Printed/Typed Name a 71' <br /> th Day Year <br /> A <br /> N <br /> Z S , 2 , -�r• 1 <br /> w P 1 1 1 1 <br /> �v O 18.Transer 2 Acknowledgement of Recel o M erials <br /> R Printed/Typed None Spnature Month Day Year <br /> w T <br /> LL E <br /> 0 R n r•-e. I Its Li <br /> QF 19.Discrepancy Indicotion Spore <br /> U A <br /> C <br /> 1 <br /> L <br /> 1 20.Facility Owner or Operator Certification of receipt of hazardous mderkah covered by the manifest except as noted In tem 19. <br /> T Printed/Typed Nance Slgnalure Month Day Yea <br /> Y 1f�1 � f. �.)a: d.5 � i ,,,...yi-.�,�,--.rp� ld!`"�-„�,,..+r"^”' '' I � 1�' Imo° ( •r t '` <br /> DO NOT WRITE BELOW THIS LINE. <br /> DHS8022A(12/90) Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHN 30 DAYS. <br /> EPA 8700-22 <br />