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• _• ^rw-*Q---0nu.euau—uw8(Expires9.30 UepartmentofHealthService <br /> Please print Or type. (Form designed for use an ellt,*'"-pitch typewriter). a Toxic Substances Control Divisio <br /> j Sacramento,Californi <br /> ~: <br /> UNIFORM HAZARDOUS lenerator's US EPA iD No. Manifest z. Page t <br /> WASTE MANIFEST ,�� Document No. Information in the shaded areas <br /> L'' f `r_' of is not requir@d by Federal kaw. <br /> L71", <br /> enerator's Name and Bing Address A. State Manifest Document Number <br /> t�" i✓. ,1%t.. � <br /> B. State Generator's ID <br /> a. Generator's Phone(¢�, �) a " <br /> S. T ns orter] Cam an Nam 8. US EPA 10 Number °f C. State Transportsr'a t <br /> n I i <br /> 04 <br /> 1 f 7 "Y 7", r^; J t r" D. Transporter's Phon <br /> 7. Transporter 2 pany Name 8. w US EPA ID Number <br /> If E. State Transporter's M <br /> ! F. Transporter's Phone <br /> 9. pesionated F� ID Number cflity Name and Site Add sa 10. US EPA <br /> �f 1 /y t G. Slate)Faciiity'9ID <br /> (+ l ti, ��VC 1l ..l ~ •, r F _ ' <br /> a J. H. F cilitY's Ph no <br /> ff ' <br />(n O j 12. Containers 13. Total 14. 1 1. <br /> u_ 11. US OOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No- <br /> J tj No. Type Wt1Vai f <br /> 4 <br /> U a. <br /> �_ N :� EPA/Other 1 <br /> r� <br /> w• N R bCo <br /> i! State <br /> O A <br /> T I EPArOther <br /> C%t O <br /> Ir R C. State w <br /> I <br /> EPA/Other <br /> I { <br /> w d. I# I <br /> Z State <br /> i <br /> w � <br /> U �! EPA,Other <br /> w E <br /> Oa. <br /> Additional Descriptions for Materials Listed Above i K. Handling Codes for Wastes Listed Above <br /> a C i a, h. <br /> W a <br /> C !. <br /> C. d. <br /> T <br /> Q i <br /> 15. Special Handling Instructions and Additional Information ig <br /> Z )t <br /> J I i <br /> J <br /> a <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> a and are classified,packed,marked,and labeled,and are in all respects in proper condition for tiansport by highway according to applicable international and <br /> hnational government regulations. a i <br /> fr If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> O to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> } present and future threat to human health and the environment;OR,it l am a small quantity generator,I have made a good faith effort 10 minimize my waste <br /> CJ generation and select the best waste management method that is available to me and that i Can!afford. <br /> Z F <br /> W <br /> O Printed/Typed Name ture i Month Day Year <br /> Signa <br /> 7 <br /> W T 17. Transporter 1 AcknowledgementofReceipt at Materials { <br /> R <br /> APrince <br /> N yped Name Signatur /•`' Month Day Year a <br /> P r r L ) i <br /> O 18. Tra6sporter 2 AcknokiedgerAeril of Receipt of Materials <br /> UR Printed/Typed Name Month Day Year t <br /> T Signature <br /> E <br /> Z R <br /> 19. Discrepancy Indication Space e 1 <br /> F <br /> A j <br /> C SS <br /> L <br /> I 20. Facilit Owner or O eralor Certification of receipt of hazardous materials eovere by this man' st except a noted in Item 9. <br /> T <br /> y Printed Name Signature ,) Month 10ay Year <br /> DHS 8022 A(1 8) Do Not Write o his Line.r J <br /> EPA B70t}--22 <br /> (Rev.9-88)Previous editions are obsolete. <br /> YeIIOw: TSDF SEN THIS COPY TO GENERATOR WITHIN 30 0:,' <br /> 4 <br />