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w1 - <br />'Slate of California .-Health and Wella Agency j+ '04 ..'; ;�?j:t -6 ,0 I .. �-i! • p_ lhwsomc1 <br />Form Apprfovbd OMIT Nd,205Q-�b39 (Expires 9-309 <br />Please pant or tvoe. (Form designed for use on elite itch tvoewriter1 <br />Department of Health Servi( <br />Toxic Substances Control Dwis <br />Sacramento. Califon <br />DHS 8022 A (1/88) / / Do Not Write�oW This Line LIZ EPA 8700--22 l <br />(Rev. 9-88) Previous editions are obsolete. <br />WHITE: TSDF RETAINS <br />UNIFORM HAZARDOUS <br />1 1. Generator's US EPA tD No- Manifest <br />2. Page II <br />informationin the shaded areas <br />WASTE MANIFEST <br />.iDocum,nt�No. <br />of 1 <br />is not required by Federal law. <br />3. Generator's Name and Mailing Address1 ; <br />'v �$e �.i-=s! ilc•.a a <br />A. State Manifest Document Number <br />.� <br />j14C-1.1, 1.111. ..:fl�tf. ANY. Pi) FOXF, � : i1F:i,). `TA I`•'te <br />89570058 <br />r1 l n J'; 3) �.•"' 7 1'.Z. <br />B. State Generator's ID TAY V) f40. <br />4. Generator's Phone( rn-..L. �Y <br />IF: <br />C� <br />5. Transporter t mpany Name 6. US EPA ID Number <br />C. State Transporter's ID <br />d?n,n,ri& n4 FFP�P1 N , 1 r. i <br />D. Transporter's Phone <br />41 5 G3. <br />7. Transporter 2 Company Name 8. US EPA10Number <br />E. State Transporter's ID <br />F. Transporteel; Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G- State Facility's ID <br />ERI 'E30 . INC. <br />yj A11211no91�I�*��'I?��IZ <br />«55 PARR BOULEVARD <br />H. Facun 's Phone �— � <br />t 10JIMONEY, '.'.r 94301, h 1 <br />415/235-13"43 <br />�t?/i <br />12. Containers <br />13. Total <br />14. <br />1. <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity <br />Unit <br />Waste No. <br />- <br />No. <br />Type <br />Wt/Vol <br />° <br />a. <br />tete 5 12 <br />G <br />Wa-tc E61p'ty Ulldi" l-n.'Ilfid Stctragc Tank 8 i <br />EPA/Other <br />N <br />"Cas ifc;rnia Re W-Sstl. f) 1 " <br />2tx' <br />T P. <br />- `� �� <br />( c <br />F` <br />IL4a <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 for Materials Listed Above .. <br />IC_. Handling Codes for Wastes Listed Above <br />rDietssciicrapttiiotnns <br />ZKPTY <br />IL b. <br />IL <br />15. Special Handling Instructions and Additional Information <br />WEAR GL(WES WHEN HANDLIMP, <br />16. <br />i!9991 <br />GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately des U1, t p H <br />and are classified, marked, and labeled, in in i�t2 <br />packed, and are all respects proper condition for transport by <br />national government regulations. <br />highway N$oa6lfa dT <br />q r <br />1s .� <br />i 3# i$ i /'ERMES <br />If l am a large quantity pry p ty o <br />rg q ity genereto, I certify that 1 have a ram in Ecce to reduce the volume and toxicity of waste genera to the degree I have determined <br />to be economically practicable and that 1 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, is 1 am a small quantity generator, I 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 1 can afford. <br />Printed/Typed NameSin <br />re <br />ON BEHALF' OF Month Day Year <br />aL <br />Rt <br />. t no I "ant 6T Receipt of Materials <br />Transpo <br />A <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />I <br />O <br />RPrinted/T <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />S <br />YP ed Name <br />Signature <br />Month Day Year <br />E <br />19. Discrepancy Indication Space <br />A <br />C <br />1 <br />L <br />1 <br />20. Facility, er or Operator Certification of receipt of hazardous materials covers b manifest except as noted Xfteni 19. <br />T <br />y <br />Printed TY d Name <br />1 <br />Signature <br />Month Day Year <br />01$4 0HZ <br />+ <br />/ '\' (..r <br />DHS 8022 A (1/88) / / Do Not Write�oW This Line LIZ EPA 8700--22 l <br />(Rev. 9-88) Previous editions are obsolete. <br />WHITE: TSDF RETAINS <br />