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State of Cahfom+a--Health and Welfare Agency Department of Health Services <br /> - Form Arroroved OMIT No 20Toxic Substances Control Division <br /> 50--0039(Expires 930 91I' Sacramento California <br /> tease print or type (Form designed for use on ehn pitch typewrder) ! <br /> UNIFORM HAZARDOUS Generator a US EPA ID No 1 Manifest 2 Page 1 information m the shaded areas <br /> WASTE MANIFEST C10101015 1 Z �Dd&,ren,5o of +s not required by Federal law <br /> 3 Generator a Name and Mailing Address �1�M�Sri<-,A LLQ A� `� f! A State Manifest Document Number <br /> 90 <br /> r t ! y 8 tate Generator's ID <br /> 4 Generator a Phone � ) i �� >r1 t D \ � � G T" LO-30 ` 1 <br /> Loti <br /> 6 Aransportet 1 Compa ame 8 5 PAI bar CD State Transporter a <br /> Transporters Phon <br /> N {V ^� V <br /> 113 7 Transporter 2 Company Name a US EPA ID Number E State Transporter s ID <br /> a7 <br /> a 1 1 1 1 1 1 1F Transporter a Phone <br /> - 9 Designate Facility Name Site Address 10 US EPA ID Number G�,Sta FP-c"IN <br /> D R ,l <br /> J Y L�5�^ ! (r flf (i! 7 <br /> el <br /> C S 5' 'Parr ,V H F ei it -a Phone <br /> �\C� MOV\a � q�3o -� 3 q t 4 s �.Z35 Iia 3 <br /> !X 12 Containers 13 Total 14 I <br /> O <br /> 11 US DOT Description(Including Proper Shipping Name Hazard Class and ID Number) Quantity Unit Waste No <br /> Na Type Wt Vol <br /> J <br /> a W�r��� Frp Q 1 , JON — C' f �.f� G}k (� State <br /> Sr C' A or�6e t r�1� Wit t•„iJ`r `V! V C .Vf 0) 0 I V nPAeQther <br /> E <br /> N <br /> E b State <br /> ni R <br /> M T EPAlDther <br /> N O <br /> Ir R c State <br /> ' r7 <br /> EPA10ther <br /> W d State <br /> I— <br /> w <br /> ' 0 <br /> EPAr Other <br /> U <br /> ut <br /> U) 4 Additional escriptiona for Materials listed ove O K Handling Codes for Wastes listed Above <br /> Gnn�y i eacho�i ne-� yy 9 Z-- I a D t b <br /> tL2d w ►+�r1 1� � y��� � � d <br /> J <br /> C <br /> Z <br /> 0 <br /> ' Q 15 Special Handling Instructions and Additional Information <br /> Z <br /> 1L <br /> ' J <br /> J <br /> U <br /> 16 <br /> J GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and are claasihed packed marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and <br /> a national government regulations <br /> N <br /> 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 t have determined <br /> 0 to be economically practicable and that 1 have selected the practicable method of treatment storage or disposal currently evadable to me which minimizes the <br /> >. present and future threat to human health and the environment OR if I am a small quantity generator I have made a good faith effort to minimize my waste <br /> U generation and select the best waste management method that is available to me and that I can afford <br /> ' W ted! y d Name S re Month Da ear <br /> Q-?r .� �11�(Yaf LA � �Pcc�L � Il�t��'----- 1111 1 15� D <br /> WT 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> 4A mtedlTYp�Q Signature / 12ar Mpnth <br /> N l�I CfiJ <br /> u- S <br /> O P 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> W O <br /> in R Printed/Typed Name Signature Month Day Year <br /> U T <br /> E <br /> 2 <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> ' c <br /> i <br /> L <br /> I 20 Fact[ty Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> T <br /> y P inisd/Typed Name Signature Month Day Year <br /> 'DHS 8022 A(1188) Do Not Write Below This Line <br /> EPA 8700---22 Blue GENERATOR SENDS TKIS COPY TO DOHS WITHIN 30 DAYS <br /> '(Rev 9 881 Previous eddions are obsolete <br /> To P 0 Bax 400, Sacramento, CA 95812 0400 <br />