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State <br />of <br />Cahfo n4iron Protection Atgency <br />on <br />g�,,��9 fres 9-30 94 ` See Instructions back age, 6. Department of Toxic Substances Control <br />Form APProved �q, . �Y� (Exp ,. �. <br />'' Form for typewriter. Sacramento, California <br />PI <br />a <br />p alar h desk, use on (12•phl <br />A <br />tj <br />(FORM HAZARD®US <br />1. Generator's U$ EPA ID No. ` ' Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />is not required by Federal law. <br />�f '.WASTE.- MANIFEST <br />36 <br />of <br />3. Generator'sNillfhe and Mailing Address f `1� ; r }.( <br />l <br />1 <br />4. Generator's Phone .kLV <br />5. Transporter 1 Company Name b. US EPA ID Number <br />O . <br />OMRONME14TAL SERVICES <br />A <br />� <br />Q <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />V <br />e n. <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />O <br />A <br />U <br />Z <br />tfiillo"OL <br />e <br />dA 1" <br />Total <br />T Quantity <br />WW U nit <br />t/Vol <br />11': US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />No. <br />Z <br />a, 1111 1111, All i <br />WA QUM <br />E <br />N00 <br />N <br />b. <br />E <br />N <br />R <br />`. <br />A <br />'T <br />;, C. <br />a. <br />R <br />FW <br />— <br />Z <br />ut <br />w <br />N <br />Z <br />a , <br />J <br />Q <br />® <br />,. <br />15, Special Handling Instructions and Additional Information <br />7040 <br />24 NM 94MMQ <br />Z <br />av <br />_ <br />; <br />H <br />J <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above' �y proper shipping name and are classified, ' <br />�( <br />packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable federal, state and international laws. <br />J <br />If I am a large quantity generator, 1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br />economically practicable and that I have selected the practicable method of treatment, storage, or disposal cur?ently available to me which minimizes the present and future <br />CL <br />H <br />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 generation and select the best <br />waste management method that is available to me and that I can afford. <br />"Year, <br />Month Day <br />O <br />Printed/Type erne <br />Signature " <br />.: f <br />Z <br />t• <br />`' 17. Trans iter 1 A . nowled ement of Receipt of Materia <br />1ZLUM- ' <br />SignatureUj <br />Day ea <br />rY <br />A <br />a <br />Prnted/,Typed Name <br />4 <br />W <br />6 <br />18 Transporter 2 Acknowleclaisment of Receipt of Materials <br />Month Day. " Year -' <br />T <br />Printed/Typed Name <br />Signature <br />I.L. <br />O <br />e <br />in <br />19. Discrepancy Indication Space <br />V <br />F <br />A <br />Z <br />e <br />C <br />1 <br />I <br />20. Fail Owner or Operator Certification of recei t of hazardous materials <br />covered by this manifest exce t as noted in Item 19. <br />T <br />Printed/Typed Name <br />Signature <br />Month Day " Year <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (12/91) <br />EPA 8700-22 Yellow: GENERATOR RETAINS <br />