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cc <br />Lu <br />F <br />Z <br />W <br />U <br />W <br />0) <br />Z <br />O <br />0. <br />N <br />W <br />Ir <br />State of California—Health and Welfare Agency <br />Fo#m Approved OMB No. 2050--0039 (Expires 9.31W <br />Department of Health Servic <br />® Toxic Substances Control DIViy <br />Please <br />print or type. (Form designed for use on 2 -pitch typewriter). <br />Sacramento, cantor <br />UNIFORM HAZARD®l1S i. Generator's US EPA ID No.Manife <br />2. Pepe t Information in the shaded areas <br />Document No. <br />o. <br />WASTE MANIFEST -7L 1 <br />of is not required by Federal law. <br />3. Generator's Nameand Mailing Address <br />A. State Manifest Document Number <br />+� dd <br />a tt ti.R t 9� g, '' fk .�'« ✓ �1 % Ix a /1 <br />�uo �d �r1 c1 � ii 7 <br />k), State Stenprator'a.� - _ <br />4. Generator's Phone r), e. _. i, , s 't 1Y ,. <br />s ` J. <br />5. T ns orter Com any. Nam 8. US E A ID Number <br />C. tate'Tren o sr`s <br />D. Tranaporter's Ph <br />7. Transporter 2 Company Name tjS PAI Numbe► <br />E. 'State Transporter ' <br />F. Transporter's Phones, <br />8. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's 10,'. <br />°'; tt+f <br />JV <br />M. .aallity Rfan� <br />- <br />12. Containers <br />13. Total <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 />,��° <br />ei..� <br />,State <br />N <br />j r <br />E <br />b. <br />State <br />R <br />A <br />EPA/(?titer <br />T <br />O-,. <br />R <br />C <br />Mata ., <br />Amthar <br />d. <br />Mate ' <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. ;Handling Codes W'Wastes <br />List" Above <br />r v <br />a. <br />b. <br />§} <br />C. <br />d.77 <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 labeled, and are in all respects in proper condition for transport by highway according to applicable international and <br />national government regulations. <br />If Lam a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree 1 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 />present and future threat to human health and the environment; OR, if I am a small quantity generator, 1 have made a good faith effort to minimize my waste <br />generation and select the best waste management method that is available to me and that I can afford. <br />Printed/Typed Name <br />r' <br />Signature Month Day Year <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A <br />N <br />Printed/ Typ*14Te <br />Signaturer- Month Day Year <br />S <br />P <br />41, <br />18. Trani r 2 Acknowledge ant of eceipt of Materials <br />TPrinted/Typed <br />NameSignature <br />Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />T <br />y <br />Printed/Typed Name <br />Signature Month Day Year <br />DHS 8022 A (1/88) <br />EPA 8700-22 <br />(Rev. 9.88) Previous editions are obsolete. <br />it Do Not Write Below This line <br />• i` <br />