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4hallfO <br /> : Fo Approved OM-N o.2 and Welfare Agency See Instructions on F of Page 6 Department of Health Services <br /> Form Approved OMB No.2050-0039(Expires 9-31 9 Tozic Substances Control Please print or type. Form designed for use on stile f J-pitch typewriter). - and Front of 1-- 7 Sacramento, l ifomie <br /> . l Division <br /> t <br /> UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> t WASTE MANIFEST 1 " <br /> t of/ is not required by Federal law. <br /> eneretor'n45y <br /> N`e'Men) Mail Ad esss _ ^^� <br /> fKid— .�' `�,.. �$/`F F �.� f --y�'z��) f �/ A. State Manifest Doeu13 5 <br /> rpsnt�lumbelL <br /> +'�'�� "'+'1 ' � TS37 e. State Generator's ID4. Generat /S}: ' d6 antipoNaN ny '` 8. U EPA ID Number C. State Transporter's ID01 <br /> n <)Q< /I�+��r 'a p D. Transr` p01'fer'a P11one ^n 7. Transpony N e e. US EPA ID Number E. State Transportera ID10g .. . ,�- ?M,"•:,., - ., :• ", .r F. Trattapartar'0 Phone <br /> ? 9. eai�p,,p[ated Faciility NN nd Wress 10. US EPA ID Number G. State Facility's KY <br /> i J �SJ A <br /> C) <br /> - '� "" /,�' � H. FaciHty'a Phone <br /> O -a 12. Containers 13. Total 14. L <br /> 11. US DOT Descriptio cludinp Proper Shipping Name,Hazard Class.end ID Number) Quantity Unit Waste No. <br /> Wt/Vol <br /> C" 3 ' N <br /> �.aD�� E b. � <br /> Q)&a.iii R R State g <br /> 53j EPcu# ` <br /> a R C. <br /> Stats <br /> 'r d. S <br /> I _ State , <br /> EPA/OMar <br /> W 7yf r i <br /> O J. Addit Deseript for Matterrhats Limed Above /�1;941 44 ` K. Handling Codes for Wastes Lfetad,Abays <br /> ta <br /> ut <br /> a <br /> Kik � i <br /> ut <br /> Z5 0 <br /> z r" <br /> O <br /> F 16. Speciq ling I tr tions nd Addi to"na,�Ieformati �. � 10F r <br /> Z 771C <br /> Z-40 lwzoutr <br /> W <br /> '54 t <br /> J •Y <br /> 1114 <br /> O In <br /> NER R'S CERTIFIC TON: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J are Bellied,pack d141 and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> onal ernment reguletfona. <br /> m a e quantity geneMtor,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree 1 have determined <br /> p e ec mically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> sent a future I real t hsman health and the enJironment;OR,i(1 am a small adtity ggnerator,I have made a good faith effort to minimize my waste <br /> eratio nd select the,beat waste management Method that is available to me. nd'that I can afford. <br /> Z <br /> WTyyppe-d' me Signator Month Dey Year <br /> Lu S W T sports Acknowledgement f Receipt of M erialsRGA d me ��,,, SI atur LL S Month Da Year <br /> O pyW O sporter Acknowledgement of Receipt of Materials <br /> a R Printed/Typed Name Si nature <br /> U E Month Day Year <br /> 2 <br /> 19. Discrepancy Indication Space � <br /> FIA �. <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Printed/Typetl Neme Signature Month Day Year <br /> DHS 8022 A <br /> EPA 8700-22 Do Not Write Below This Line <br /> (Rev.8.89)Previous editions are obsolete. <br /> YELLOW: GENERATOR RETAINS <br />