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6 -Health and Welfare Agency <br /> ;ad OMB Na M-0039(Expires Department of Health Services <br /> See Instructions an bat��f page 6. Toxic Substances Control Program <br /> Print Of type. Farm designed thr use on elft(f2-pinch-p#N • Sacramento.Colifomia <br /> Pagel in the shaded areas <br /> UNIFORM HAZARDOUS I.-G-ene It Manifest c erd.110. 2. e I Womartion <br /> EST I Generalors /I P, <br /> WASTE MANIFEST III IL 10 to 10 10 14 1 .1 1 3 1 4, 11 17 17 171 of I I is not required by Feclerd law. <br /> 3.Cer*roloes No"and Mcang tj'Yo*a92swA1 <br /> e <br /> 01unbe <br /> 0STIP ARIETf ITHE 1132 <br /> q <br /> AGeneatoft Phorw & 1MITRPJISE SREET CA 94531 ; <br /> 5.Transporter I Company Name 6,LIS EPA ID Number C Sfate Trvsporfor 8, <br /> C A I 0I 3I 8 I 1 11 3 <br /> 110EL TRANS. I 11C. <br /> 7.Transporter 2 Company Name 8. <br /> US CPA ID Number <br /> DPW <br /> 4 A CIO 0 4' <br /> 12 !2 <br /> . wi,'T reporph� <br /> 9.Q�6;d.IEFOcilt fatNime and Site Address 10.US EPAIDNumber s <br /> cdQp ACA DI 01 4 3 2 1 0 1 41.:0 lirly.sp 130 <br /> 0 ::V <br /> I 94061 1 1 1 1 1 1" <br /> . <br /> 111.LIS DOT Description(Including Proper Shipping Nome,Hazard Class.and ID Number) ___NoF_Type 12.bont ners 13.Told 14unit <br /> Quant'v VAIVOI <br /> N. <br /> a..(NATER <br /> IMN 11GASOLIVE)fee"' EWITO T 8 7- 1 F-7 1/ 1 <br /> z <br /> WillCX E Its. <br /> 2s state <br /> C0=I R <br /> V4< A r sz <br /> S ..... <br /> .......... <br /> 0 <br /> ................ <br /> Rf <br /> ' In <br /> .......... <br /> CL <br /> Iq 1�141 <br /> .. . ........ <br /> K1. <br /> Lu <br /> I&Special Handling Instructions and Additional information <br /> LIS GLOVES, GMEES S APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> z <br /> 0 <br /> FREOUNCY CONTACT- RICH 4AILOW-410-659-0404 <br /> Q. <br /> Z I& GENERATORS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are cassifed, <br /> packed,marked.and labeled,and are Inallfpspects In proper condition for transport by highway according to applicable International aid nalioncslgovismwent riegubatlaa <br /> If I am a large clucinfity gencirator.I certify that I have a program In place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> economically practicable and that I have selected the Practicable method of treatment,storage,or disposal currently al-nilabie to me which minirrilm the present and future <br /> threat to hurricin health and the environment,OR.If I am 0 1111`1011 Quantity gfimlaftr.I have mode a good forth effort to n*ftize my waste generation and select the best waste <br /> management method that Is available to me and that I can afford <br /> Pflinted/Typed Nome Signature Month Day yea <br /> 9'1 -4 <br /> to T 17.Transporter I Acknowledgement of Receipt of Materials <br /> 0 R Pdnted/ryped Nome Signature <br /> j — 1� — qm—th Day Yea <br /> > A 71-?A joe 71 <br /> Q N lee 0 <br /> Z 3 <br /> Is <br /> 0 18.Trans porter2AcknowledgementofRete ipt of Materials <br /> R Pdnted/TYPed No" SkFX3hffe <br /> T <br /> E <br /> 0 R <br /> 61 C ti 0 4 4�l f*J0 A,1 <br /> F 19.Discrepancy Indication Space <br /> A <br /> C <br /> L <br /> 1 20.Facility Owner or Operator Certification of receipt of hazardous materk*covered by this manifesil except as rioted In Item 19. <br /> T Plintediflyped N'"" Signature Monffi Day y6cil' <br /> Y <br /> G1 al'7 6 <br /> DO NOT WRITE BELOW THIS LINE. <br /> DHS8022A(I2/9M Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS, <br /> EPA 5700-22 <br />