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C <br />U <br />G� <br />State of Ce1i!ornla-4,4e_tth and Welfar-0039e AgeXpires �� <br />Form ADDrovM OMB No. <^D50--O(13g (ExDirea 9.30- <br />Pianae of UNIFORM <br />or type. (Form designed for use onn'I -pitch typewriter). <br />UNIFORM HAZARc®coUJ Gonr rMOI's QUS FPA ID NO. g p j� � Mamte,0 <br />WASTE MANIFEST Z% -I <br />1 <br />3 etatof.SN Pm nd me d'np Address- <br />4. <br />ddress <br />1 24�Dp G�'tM► rip J� <br />4. Generator'*, Phone (146) LP I _LL 33 ra q4 <br />$, Transporter / Company Noma 8. S >:Ppl[u�a� <br />NN me 3. US EPA ID Number <br />} ; , Trnnaponer ,> Company A <br />toto <br />W <br />J <br />J <br />{ <br />U <br />Lit <br />r <br />c <br />El <br />P I)A%igGloS ®�-80 <br />NAM9 AAA Site AddrA3= <br />10. US EPA 10 Ntlmbet <br />K�ctwDir .. j Q%4(2>0 <br />11. US OOT Description VACludiog Proper Snipping Name. Hazard Ctae3. And ID Numbnr) <br />yr��.�� <br />G { _ a�arda v.a 1�J.�y 1 dot_% J <br />E <br />N <br />E b. <br />R <br />A <br />T <br />O <br />R C. <br />i <br />S <br />a <br />A <br />N <br />S <br />P <br />O <br />R <br />T <br />F <br />A <br />C <br />L <br />I <br />T <br />Y <br />d. <br />Depanme-a of Health Services <br />Toxic oubde�Ces Gcnttol Dlvia-Jr <br />Sacramento. California <br />2 Page t �1I information .n the AheOed areae <br />of i iA not te0viraQ by Fedarat law. <br />A. State Manll5et_Po4urg_Gn1NLfr!bjL .se <br />B. State <br />/Geenneral*?.8 it <br />C. 81ete T ®napate a <br />E. State Tranaporter's 10 <br />F. 7ranaPOTAV-a Phone <br />G. State Facl1hy's ID <br />mmm <br />A/ <br />K. Handling COdo$ tot Wastes L00*0 Above ' <br />,t, Additional DeaCtipifon.• SOt Materiels Listedtt0�� t ` e�Tt_ 1 A b. <br />mQ}y VeQse 1 I uAQ "71tt///Nlt/l� ITZ <br />VrN�Q �QG1jt►1 Llf1�-\ L�CGQt� d. <br />VT yam. `Q6(0 <br />15. Special Handfino instructions And Additionai Information <br />le. <br />GENERATOR'S CERTIFICATION: I hereby declare that the contonlS Of this COnaignmwni are fully and accwplely d;scribed above by PrOper 84111)ptng r19m* <br />Ono are classified. packed. marked, end tebeled, and Are In all respect* in propat condition for transport by highway acCord;n¢ to aPPlicat.le intCrnationat and <br />national government regulations. <br />If i am a large Quantity gonerntor, I certify that 1 have A progrnm in place to reduce the volume, ono toxicity of wASIg generated to the dvortt I rave detemmhtrd <br />to be econom;cally practicable And that i +rave aefected the practicable method 01 treatment, storAgt. Or disposal currently evadable tb mf. which minimizes the <br />pree9nt and futurC threat t0 human health and he crvironmcnt; OR, it I am a a-% 1 Qvnn!ity generator. !nave n+adC a Hoed fe!1h a»ort to rtinimize my wa2tC <br />generation and select the b9st wa3to mor.age of method that in Avrtdnbte t0 rA°end that I ce.n 6. n <br />nntur / �Afonth Day <br />Pr`nl''' <br />�Rd'/Ty ed Name t A���.,���� I <br />ansponer t Acknowledgement of Rel <br />C ipt Of <br />3/Typed Name <br />a400�[/R �yUay revel <br />18. Transporter 2 ACknOwieOpement of Receipt of Meter;W$ <br />Month Day fear <br />Printed/Typed Name I Sisnature <br />19. Discrepancy Indication Space <br />20. Faculty Ownet or 0", rotor Ce <br />Printed/TYDed NAnte <br />DhS $022 A (I IN) <br />EPA 8700...-22 <br />® (Rev. 9.83) Previous edltlone are obsolete. <br />of receipt of ha7.Ard0Ws metCrinis Covered Dy Ilya manlf98t eXC9r^t A$ noted m nem 1F. <br />SiQnsture <br />Do Not Write BelAw This Line <br />Blue: GENERATOR SENDS THIS COPY "O DOHS WITHIN 30 DAY <br />To: P.O. Box 400, Socromento, CA 95812.Oe,0J <br />i 1 -, 1.v11 ^ . _ . I_,y I o_Il n_•i .1 .M! tm I !j['a_i._��r. w� I��� ,_.� .. i b i pr, 1. -Z._ -,]Q'. <br />H. Facf,; ' t'honq <br />L[C <br />12. Conlain9ra <br />No. <br />13. Total <br />Quantity <br />1 Type <br />14• <br />Unit <br />Wt/V0 <br />1' <br />NO. <br />Ste:te <br />h tt <br />i <br />State <br />EPA / Other <br />A/ <br />K. Handling COdo$ tot Wastes L00*0 Above ' <br />,t, Additional DeaCtipifon.• SOt Materiels Listedtt0�� t ` e�Tt_ 1 A b. <br />mQ}y VeQse 1 I uAQ "71tt///Nlt/l� ITZ <br />VrN�Q �QG1jt►1 Llf1�-\ L�CGQt� d. <br />VT yam. `Q6(0 <br />15. Special Handfino instructions And Additionai Information <br />le. <br />GENERATOR'S CERTIFICATION: I hereby declare that the contonlS Of this COnaignmwni are fully and accwplely d;scribed above by PrOper 84111)ptng r19m* <br />Ono are classified. packed. marked, end tebeled, and Are In all respect* in propat condition for transport by highway acCord;n¢ to aPPlicat.le intCrnationat and <br />national government regulations. <br />If i am a large Quantity gonerntor, I certify that 1 have A progrnm in place to reduce the volume, ono toxicity of wASIg generated to the dvortt I rave detemmhtrd <br />to be econom;cally practicable And that i +rave aefected the practicable method 01 treatment, storAgt. Or disposal currently evadable tb mf. which minimizes the <br />pree9nt and futurC threat t0 human health and he crvironmcnt; OR, it I am a a-% 1 Qvnn!ity generator. !nave n+adC a Hoed fe!1h a»ort to rtinimize my wa2tC <br />generation and select the b9st wa3to mor.age of method that in Avrtdnbte t0 rA°end that I ce.n 6. n <br />nntur / �Afonth Day <br />Pr`nl''' <br />�Rd'/Ty ed Name t A���.,���� I <br />ansponer t Acknowledgement of Rel <br />C ipt Of <br />3/Typed Name <br />a400�[/R �yUay revel <br />18. Transporter 2 ACknOwieOpement of Receipt of Meter;W$ <br />Month Day fear <br />Printed/Typed Name I Sisnature <br />19. Discrepancy Indication Space <br />20. Faculty Ownet or 0", rotor Ce <br />Printed/TYDed NAnte <br />DhS $022 A (I IN) <br />EPA 8700...-22 <br />® (Rev. 9.83) Previous edltlone are obsolete. <br />of receipt of ha7.Ard0Ws metCrinis Covered Dy Ilya manlf98t eXC9r^t A$ noted m nem 1F. <br />SiQnsture <br />Do Not Write BelAw This Line <br />Blue: GENERATOR SENDS THIS COPY "O DOHS WITHIN 30 DAY <br />To: P.O. Box 400, Socromento, CA 95812.Oe,0J <br />i 1 -, 1.v11 ^ . _ . I_,y I o_Il n_•i .1 .M! tm I !j['a_i._��r. w� I��� ,_.� .. i b i pr, 1. -Z._ -,]Q'. <br />