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btate of caumr w—matin end ♦uare^04mcy r,� •.• "I _lfuj F �� r r f <br />App 9N tY rS 1 „L:� )1 F'.; i< 1FW.S: MF <br />Form roved o. 205*--0b39-(EXpire99.39 <br />Please —int nr tune- !Form desicned for use'on dlite 112-0 • oewriteA_ <br />-� Department of Health Services <br />Toxic Substances Control Division <br />Sacramento. California <br />DHS 8022 A 0 /88) /t - <br />Do Not Write Below This Line <br />EPA 8700-22 <br />(Rev. 9-88) Previous editions are obsolete. <br />WHITE: TSDF RETAINS <br />I <br />UNIFORM HAZARDOUS <br />1. Generator's US EPA ID No. Manifest <br />2. page 1 <br />Information in the shaded areas <br />WASTE MANIFEST <br />Documgnt o. <br />" r. ,7 G It fl L 7 3 i ; G s � C. <br />of i <br />is not required by Federal law. <br />3. Generator's Name and Mailing Address ;i;{t+1 ,t:::`�q� !�*,; -.3. i TE- <br />A. State Manifest Document Number <br />( <br />J77FAau Oil, • ..'i`rf �'�e f3 i� i'".i ��'��.', .. �:`rs l: ilCiti: 6�A 111 `AN <br />$ <br />,i l ? 5 't p ol- y ; UV D , <br />B. State Generator's ID t, Ah I D 140 . I <br />4. Generator's Phone ( i ri :� I f ] .., 'i�{:•;j;ri` . .fin is r "'w <br />` <br />5. Transporter t Compoly Name 6. US EPA ID Number <br />C. State Transporter's tD <br />�R{ ti''fAP�3[415/633-033-6 <br />D. TasporeesPhne??� <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E- State Transporters 10 <br />F. Transporters Phone :. <br />9. Designated Facility Name and Site Address 10. US EPA 10 Number <br />G- State Facility's 10 <br />117 4_9 <br />PARR R'"�f'LF'v ni':!, <br />K Facitity'l Phone _ <br />D rl 11 9I 4 ti 31912 <br />C <br />415/235-1393 <br />t; <br />_ <br />12. Containers <br />13. Total <br />14. <br />L <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity <br />Unit <br />Waste Na. <br />No. Type <br />Wt Vol <br />a. <br />State <br />G <br />j fig} af4ii,t v Ef'tt,�?7 yl'•'r?lltti t t(,I' eCiQiiili. t? -dV' <br />�5 <br />E <br />h - <br />t:3iiL l(t(:Y P,!totilated wast, Orilvrt <br />�` Q <br />= <br />P <br />N <br />E <br />b. <br />State <br />R <br />A <br />T <br />EPA/Other <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 He ndlmg Codes, for Wastes Listed Above <br />EMPTY UNDY.111',ROiRD MRAf'ZT i$ i <br />CONTAINING GASOLINE 144 <br />d. <br />/® ,67I4•L.TA <br />6;[[-jiU WfM <br />;x:•y F e X M Y r Ko'l ~ <br />15- Special Handling Instructions and Additional Information <br />WEAR-3LOVES WHEN HxNDLT#', R <br />MAR 1 9 1991 <br />16. L , <br />GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described ahoy}e b' . r6pex jj t z ug nemg <br />f...!kR <br />9 b i <br />and are classified, packed, marked, and labeled, and are in all rgspects in proper condition for transport by highway according to applrcabfe international end <br />national government regulations. - k <br />If 1 am a targe quantity generator, 1 certify that 1 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 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, 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/ ped Name re 'I ON BEHALF (,F Month Day Y. <br />` <br />kz,�✓/j,!! �i , i SHED 010 <br />T <br />If Transportelf t A06knowledgement of Receipt of Materials <br />R <br />N <br />Printed/Typed Name <br />Signature - Mont Day' Year <br />P <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space t <br />F <br />A <br />C <br />0/ <br />1 <br />L <br />T20. <br />Fa y er or Operator Certification of receipt of hazardous materials covered by tis anifest except as noted in Item. 9i <br />y <br />Prints{!/ d Name <br />\\ <br />Signature Month Day <br />/� <br />Q Q v / <br />jar <br />DHS 8022 A 0 /88) /t - <br />Do Not Write Below This Line <br />EPA 8700-22 <br />(Rev. 9-88) Previous editions are obsolete. <br />WHITE: TSDF RETAINS <br />I <br />