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e.. of .,.. <br />State of California—Health and Welfare Agency 6 <br />Form Approved OMS. No. 2060-0039 (Expires 9.30.9jft <br />Please print,br type j, .(form designed for use on elitoWitch typewriter). <br />UNIFORM HAZARDOUS �1. Generator's US EPA ID No. Manifest <br />WASTE MANIFA T <br />EST 0 g top (� <br />3.I? <br />.erator's Nem nd jai)ng Address <br />deli <br />Cann,nd Mor) R 3E0G0/ yarn y mMI <br />4. Generator's Phone (406) 4q1—H 33 5 <br />�j 6. Transporter 1 Company Name 6. S EPA ID Number <br />N <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />9, Resign ted Facility NAM anA Site Address 10. US EPA ID Number <br />U7 <U � s Pf;Yr' �✓� <br />tiCNM a44 QLiebO' O ® t <br />9 <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />Ej*o �bE 1 Ah <br />E - Rt.q�arcbu W- �ot-i 1� <br />Department of Health Services <br />Toxic Substances Control Division <br />Sacramento, California <br />Page 1 Information in the shaded areas <br />of r is not required by Federal law. <br />12. ContainersI 13. Quantity I Unit <br />No. Type Wt/Vol <br />30-70-0=*0 <br />Q16. Special Handling Instructions and Additional Information <br />Lvd � � <br />�h2ra�� 1a�1 W� 1M�r <br />� <br />LR e <br />U 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 />J 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 />a if I am a large quantity generator, I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br />p 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 he environment; OR, if I am a s I quantity generator, I have made a good faith effort to minimize my waste <br />V generation and select the best waste manage nt method that is available to a and that 1 can d. <br />2 <br />W4 <br />CPrinted /Typed Name LN f I V X ftnatur Month, Day Ye, <br />W <br />6 <br />WR 17. Tranap <br />Z <br />A Printed /Tyi <br />N <br />S <br />ty 0 18. Transp <br />UR Printed/Tyl <br />E <br />F <br />A <br />C <br />I <br />L <br />Name <br />Day Year <br />Signature Month Day Year <br />1 <br />T 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />y Printed/Typed Name I Signature Month Day Yearrj <br />DHS 8022 A (1 /88) Do Not Write Below This line <br />EPA 8700-22 <br />(Rev. 9.88) Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />To: P.O. Box 400, Sacramento, CA 95812-0400 <br />