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to <br />n <br />N <br />to <br />Co <br />H <br />J <br />00 Q <br />U <br />4 <br />CO Q <br />CO O <br />Nu. <br />J <br />W G <br />U <br />CTD <br />M• 3: <br />N <br />O <br />O <br />a <br />N <br />a <br />8 <br />m <br />¢ <br />W <br />I`_ <br />Z <br />W <br />U <br />W <br />N <br />Z <br />O <br />a <br />U <br />W <br />J <br />4 <br />Z <br />O <br />Q <br />Z <br />gw <br />F- <br />J <br />J <br />4 <br />U <br />J <br />J <br />CL <br />0) <br />¢ <br />O <br />Z <br />W <br />O <br />w <br />w <br />Z <br />U.O <br />u7w <br />l <br />f U <br />L <br />State dt,California—Health and Welfare Agency <br />Form Approved OMS No. 2050-0039 (Expires1) <br />Please print or type. (Form designed for use on de 112 -pitch tvnewriter). <br />Ll <br />Department of Health SerViL <br />Toxic Substances Control Div,s, <br />Sacramento, Califon <br />DNS 8022 A (1 / 88) <br />EPA 8700-22 <br />(Rev. 9-88) Previous editions are obsolete. <br />ff Do Not Write Below This Line <br />YELLOW: GENERATOR RETAINS <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest <br />ormation in the shaded areas <br />2. Page 1Til.: <br />Document No. <br />WASTE MANIFEST •+ � -• L1 't7 i <br />ofnot required by Federal law. <br />3. Generator's Name and Mailing Address <br />A. State Manifest -Document Number <br />`�1iilJ,Frt <br />1r J, <br />90009388— <br />0 r .I, <br />ilr.)u, <br />I,I e 17 <br />B. State Generator's 10 <br />4. Generator's Phone): , } <br />.9 '1 <br />f' <br />t.f <br />5. Tr nsaorter Com any Nama 8. US EPA ID Number <br />C. tate Transpo er's ID <br />/ <br />I ,. ) -� <br />D. Tranaponer's Phonq,, <br />i' <br />7. Transporter 2 Company Name US EPA ID Number <br />E. State Transporter;j ID <br />F. Transporter's Phone <br />9. Designated Facility Name and Site/ Address 10. US EPA ID Number <br />G. State Facility's ID <br />}t' .• i"`q o- + 1, , , ! I .— ! S1.. r it <br />- <br />H. acilit s Phone <br />lr 1141/ <br />ii ! s/ <br />12. Containers <br />13. Total 14. I. <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity Unit Waste No. <br />No. <br />Type Wt Vol <br />a. r <br />State <br />EPA40ther' <br />E <br />N <br />E <br />b. <br />State <br />R <br />A <br />EPA/Other <br />T <br />O <br />R <br />C. <br />State <br />EPA/ Other <br />d. <br />State <br />EPA/ Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />®� <br />a. <br />b. <br />A <br />M <br />r'11 <br />15. Special Handling Instructions and Additional Information <br />18. <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 labeler!, and are in all respects in proper condition for transport by highway according to applicable international and <br />national government regulations. <br />If 1 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 <br />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 />prosent and future threat to human health end the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste <br />generation and select the beat waste management method that is available to me and that 1 can afford. <br />Printed/ Typed Name <br />Signature Month Day Year <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A <br />Printed/Type acne <br />Signature �' Month Day Year <br />PO <br />/8. Tranap• r'2 Acknowledge ent of/Receipt of Materials <br />R <br />T <br />Printed/ Typed Name <br />• <br />Signature Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />T <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />Y <br />Printed/Typed Name <br />Signature Month Day Year <br />DNS 8022 A (1 / 88) <br />EPA 8700-22 <br />(Rev. 9-88) Previous editions are obsolete. <br />ff Do Not Write Below This Line <br />YELLOW: GENERATOR RETAINS <br />