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. I <br /> Slate of 0!..lifornia—+iealth and Welfare Agency Department of Health Service <br /> c''orm Approved OMS Na.2050-0039(Expires 9.30' ` Toxic Substances Control Divisic <br /> Please print or type. (Form designed for use on.1,_22j- fypewrifer). Sacramento,Cellforn <br /> UNIFORM HAZARDOUS 1. G. .eator's US EPA ID No. Manifest -• Pape 1 Entormstkon in the shaded areas <br /> WASTE MANIFEST Document No. <br /> of I is not required by Federal law. <br /> 3. Gpnrator's 4a CMaili Address A. State Man'i{@aLp u b <br /> W1 '� jfj/Z illi f� <br /> �LC�/ f ^ e. State Generator's ID <br /> 4. Generator's Phone ) _ C'`G <br /> W) 6. Tr p r 1)ompa ame 8. US EPA ID Number C. State Tranaporter's ID <br /> LD <br /> w fr l— ,rry ,, D. Transporter's Phone ' <br /> 'n 7. ranaporter 2 Cornbany Name 8. US EPA ID Number E. State Trarsporter'a tD.- <br /> u7 <br /> i $ F. Transporter'.Phone <br /> 9 esignated Facility Name,and Site Address/ 10. US!_EPA Number Q. State Facility a to <br /> Y V C <br /> U H. F 'lity'a P one, { <br /> ��r QZ11 /7141 e ID 4 q' <br /> 12. Containerfik, 13. Talk 14. c _;.,;: I. , <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Claes,and ID Number) Quantity Unit y:WaatsaJo' <br /> No. Type Wtivoi <br /> © ? a. u.5V2 "^�Jtr�tr�iJ/L' !rll�,rG stets <br /> G : <br /> C E <br /> NCl 41 <br /> E b. <br /> ni R State <br /> A .�,Kr:. <br /> T EPA/Other <br /> Y <br /> IT R' c. ,Slatw?t- <br /> .F.PAl.Other._ I <br /> I <br /> d• state - <br /> z J <br /> U EPArOtherUj <br /> 1 <br /> N J. Additional Descriptions for Materials Listed Above K. Handling Codes.for Wastes Listed Above <br /> O <br /> Uj <br /> Z <br /> a <br /> t= 16. Special Handling instructions and Additional Information <br /> a <br /> ui <br /> J <br /> J <br /> C 18. <br /> C] <br /> 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 classified,packed,marked,and labeled,and pre in all respects in proper condition for transport by highway according to applicable international and <br /> national government regulation, <br /> If I am a large quantity generator.I certify that I have a program in plate to reduce the volume and toxicity of waste 9e11erated to the degree f have determined <br /> Cc <br /> p 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,if I am a small quantity generator.I have made a good faith effort to minimize my waste <br /> U generation and select the beat waste management method that is available to me and that I can afford. <br /> Z <br /> i w Printed/Typed Name Signature Month Day Year <br /> yyl T 17. Transporter 1 Acknowledgement of Receipt ofMaterials f - <br /> Z R <br /> i s A Prtrt p d Name Si re Month. Day Year <br /> F LL S . 1 { <br /> O P ' <br /> W O 18. Transporter 2 Acknowledgement c Receipt of Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> f E <br /> Z <br /> i 19. Discrepancy Indication Space <br /> F y <br /> A <br /> C <br /> L <br /> 1 20. Facility Owner or Operator Cartificatio t of hazardous materials Covered by ie manifest except.ae/0 `1 <br /> i Item 19. <br /> 7 <br /> y Printed/Typed NaffM net Uffivriy ar <br /> R. <br /> DHS 8022 A(t 1 a Do Not Write Belo This Line <br /> EPA 8700-22 <br /> (Rev.9.88)Previous editions are obsolete. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DA) <br />