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+. ,tlth and WelfareAgen y p /�/ '�(�/ Department of Health Services <br /> ' ,No.2050-0039(Explres 9JI1.91) See Instructions on bac, page 6. Took Substances Control Program <br /> a. Form designed for use on ellfe(12-pitch Typewriter). Sociamento,California <br /> UNIFORM HAZARDOUS 1.Gereratoes US EPA ID No. Manifest Document No. 2.Page l Information in the shaded area <br /> WASTE MANIFEST 1(.. I 13 1 I 1 Z I '� 1 I - or not requked by Federal°'• <br /> 3. rw�r/alohm <br /> {Nae p,Wy PA�dd�ress.[ k1' <br /> f; 49 . 3..Z. $igte est AAcumagt#Jumk9r . 93ii1rQ <br /> 0 <br /> GenerByu S�7H='fit owewr 64 IV! 3y-3�s-s' I�JL .T.//�/1nr ate a : ; <br /> S T er 1 Company 6.US EPA ID Number G.Stotts Ttasporfst'f : +f <br /> MiL <br /> I I I T3Imni�.sarteysPftcrfe _:.:: <br /> 7.Transporter 2 Compay None S.US EPA ID Number :Z State Rareporar'ifD <br /> t -.. I I 1 I 1 I I I I I I >:#taro eYs Phone <br /> le :`� :. <br /> \ 9.Designated Facility Name and Site Address 10.US EPA ID Number G State RhYF O. Z <br /> AJ dl` <br /> s{f •Irr�7l►/�►r5/u� . p r1 FaraufY Pt ane <br /> 17 , <br /> 12.Contdners 13.Totoi 14 unit <br /> 11.US DOT Description(kncksding Roper Shipping Name,Hmad Ckns,and ID Number) No. T Quant" Wt/Vol L Ware Ahytitigt: .� <br /> aa sem.: � <br /> U G. < <br /> ©g E 1VA*' 4A firJ„ 6S/. �� 1 1 r� Slo {3 � w <br /> 0Z 'N ;' <br /> y <br /> rsr•Z T a ...;.. <br /> G <br /> R EPA/oat er. . <br /> CIL <br /> �Q :Qat .toi'GASsf: above. -<t .... lmgGodes hof wastes 1.htedRbova _bHr <br /> t b' <br /> ix <br /> Aq <br /> , <br /> U 18.Spooky Haxlkng Insmsctk>ro o d Additional InformationAVOW <br /> 2 6X IV t"A- Sic &.51 b'4314x) <br /> c Sn <br /> J <br /> Q 16. GENERATOR'8 CER7IFICAiION: 1 hereby declare thah the contents of this consignment ore fully and accurately described above by proper shipping name and are classified, <br /> Z pocked,marked,and labeled,and are"aspects in proper condition for transport by highway occordkng to applicable international and rational government regulations. <br /> O <br /> QIf I am a loge quastlly generator.1 ceAFy that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I hove determined to be <br /> Z econorrnk:aly practicable ave d that I haselected the practicable method of treahnent,storage,or disposal currently a✓ai able to me which minkn2es the present and future <br /> W threat to human health and the environment:OR,Y 1 am a small quantity generator,l have made a good faith effort to minimize my waste generation and select the best wale <br /> X management method that Is waAoble to me and that I can afford _. <br /> J <br /> J Phred/ryped None Spnahae Monts Qry Yea <br /> Q <br /> H T 17.Transporter 1 Acknowledgement of Receipt of materials <br /> R Printed/Typed Normo Sipnahr Month Day Yeo <br /> > t <br /> Z N �� <br /> P �. <br /> O 18.Transporter 2 Aknowladgement of Recelpt of Material <br /> R Prhted/TYped Name Signahxe Month 0.ry Year <br /> W T <br /> O E <br /> R <br /> QF 19.Discrepancy Indication Space <br /> U A <br /> C <br /> I <br /> L <br /> 1 20.Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted In Item 19. <br /> T Printed/Typed None Signature Month Day Year <br /> Y <br /> V / 17 1'7 I <br /> DO NOT WRITE BELOW THIS UNE. <br /> DHS80¢7A(12/90) Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> EPA 87OD-22 <br />