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.,,re of California—Health and Welfare Agency <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />UNIFORM HAZARDOUS 1. Generator's US EPA <br />WASTEMANIFEST <br />3. Generator's Name and Mailing Address <br />4 <br />s- <br />4. Generator's Phone 7 <br />5. Transporter I Company Name 6. <br />7. Transporter 2 Company Name 8. <br />Department of Health Services <br />Toxic Substances Control Division <br />Sacramento, California <br />No. Manifest 2. Page 1 Information in the sWdedl?eas <br />is not required by Federal <br />jDocym <br />of law, <br />US EPA ID Number <br />US EPA ID Number <br />T - b. <br />0 <br />R el',A-" 7 <br />. . . . . . . . . . <br />C. All <br />A:e <br />9. Designated Facility Name and Site Address <br />10. US EPA ID Number <br />J, <br />d y <br />C <br />d. <br />-c� <br />12.Containers <br />13. <br />14. <br />11. US DOT Description (Including Proper Shipping Name, <br />Hazard Class, and ID Number) <br />Total <br />Unit <br />No. <br />I Type <br />Quantity <br />t/V <br />G <br />E a. z <br />N <br />E <br />R <br />T - b. <br />0 <br />R el',A-" 7 <br />C. All <br />A:e <br />C <br />d. <br />an <br />15. Special Handling Instructions and Additional Information <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described <br />above by proper shipping name and are classified, packed, marked, and labeled, and are In all respects in proper condition <br />for transport by highway according to applicable international and national governmental regulations. <br />F Date <br />Prined/jyped, Name SignatureMonth Day Year <br />Date <br />T 17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A PrintedlTyped Name Signature Month Day Year <br />N <br />S <br />o <br />P 18. Transporter 2 Acknowledgement of Receipt of Materials. Date <br />R <br />T Printed/Typed Name Signature Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />c <br />I <br />L <br />,120.FItacilitem Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br />I - Date <br />Date' <br />T I <br />Y Printed/Typed Name Signature Month_ Day, Year <br />i I I . I - I - <br />DHS 8022 A (11184) YELLOW GENERATOR RETAINS 8489641 <br />(EPA 8700.22) <br />