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State of Calltorpli—Health and Welfare Agency • • Department of Health Services <br /> Toxic Substances Control Division <br /> ' Sacramento,California <br /> Please print or type. (Form designed tot use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS enerator o. / hh arrest age —, normoon i nthe shaded areas <br /> WASTE MANIFEST C p0 b &3,t6`y Qacxl�tA of) is not required by Federal <br /> ttJJ Vv VV law. <br /> 3. ner t r', affr aa6 iling,Ad1i A St e n fe t ument Number <br /> �-YY �.YY\i wCC,.+� C�, C1,r`Q�K.I' 8 4" 1338 <br /> T,2 vV'`'CA .b53 (0 Q ?r r� B. lCiDate ^e�nler-ator s ID <br /> 4. Generator's Phone ( 2b 1 1 36 "_ sYJ <br /> �j ransporser 1 Company Name S EPA ID Nu ber C.State ransporter's ID <br /> C.. I(w� wnsT� ►�Nnc�,Y,l:�-c T CHD.0UO3.Q $x-7.1 $ D.Transportar's Phone o - - 0"7(� <br /> Transporter7. Company Name id. US EPA ID Number E. tate Transporter's ID <br /> . . . . . . . . . F.Transporter's Phone <br /> a. Design ted Facility Name d Iifl Address 10. US EPA ID Number sSttattee /Facility's IID l <br /> Qy�ms�Nt— 4-y�ST1 M PM 9E Mf yl l VQo v ��& <br /> KeC4�I�v.�u+t!iiil <br /> av 01f . a H.Facili s Phone4 141,el� CA r 3 23 AT-0.ay.(o.4 4-1 .13 ZOM86-q?11 <br /> 12.Containers 13. tUnit <br /> 11.US DOT Deuription(Including Proper Shipping Name,Hazard C/ass, and ID Number Total 1. <br /> Waste No. <br /> G <br /> ^' 0 No. Type Quantity <br /> E a. HA?�9RDouS LvA5-1 I- 5o i 1 fir <br /> o�m-�� A 9189 p 6 T Od lJ <br /> A b. <br /> T <br /> O <br /> R <br /> C. <br /> d. <br /> J. Additional, iptio " or Materials Listed Above K.Ha ndling Codes for Wastes Llste Bove <br /> Q, sv, ; 11I <br /> 5.Special Handling Instructions and Additional Information <br /> �o6�Ics G love S �GQvk,?.G1J <br /> C� ►9 — Q'- �UdS7-orS <br /> 1 R'S CERTIFICATI N:I ;14declarethatthe contents ofthis consignmensre fully and accurately described <br /> above byproper shipping name and are classified,packed,marked,and labeled,and are in all respects in proper condition for <br /> transport by highway according to applicable international and national governmental regulations. <br /> Date_ <br /> Po"/Typed Nam N Sign Month Day Year <br /> l n� <br /> 09—pro I <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R Print yped Name Signet M n a a <br /> s <br /> .vim ow � S <br /> P <br /> O 18.Transporter 2 Acknowledgement or Receipt of Materials Date <br /> It <br /> T Print ed/Typed Name Signature Monrh Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> L <br /> 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T Item 9. <br /> y Date <br /> rint yped Name Signature Monfh Day Yeer <br /> Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> HS 8022 A (7/84) To: P.O.Box 400, Sacramento, CA 95802 <br /> EPA 8700-22) VK <br />