Laserfiche WebLink
State of California-Health and Welfare Agency Department of Health Services <br /> Form Approved OMB No 2050-0039(Expires 9 30 91) Toxic Substances Control Division <br /> Please print or type (Form designed for use on elite(12 prtch typewriter) Sacramento California <br /> UNIFORM HAZARDOUS 1 Generator a US EPA ID No ManifestJA <br /> 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST p 0Docum0 o <br /> 81 1 <br /> of is not required by Federal law <br /> 3 Generator s Name and Mailing Address .1', �Ar/�t �+�jil� State Mande�t Document Number <br /> CA theNc= !.(", wv-?IA 8 <br /> PQ 130V State Generatces 10 <br /> 4 Generator s Phonei ��� �� <br /> U) 5 Transporter 1 Company Nsmet xc is L-7rA NUS EPA ID Number C State Transporters ID <br /> U) NV !?, G G16 0 3 D TraneporteraPhc IAI5'R9D <br /> N <br /> m 7 Transporter 2 Company Name 8 US EPA ID Number I- State Transporter's ID <br /> o F Traaaporter's Phone <br /> C13 <br /> Designated F till am rid SltgAddress, 10 US EPA ID Number G State Facility's 1D <br /> Lorli <�p A T cx /91*. <br /> SkyI,Nc <br /> v f�� H Facility a Phone <br /> Z �E �tlt'1.4 N 14r IIS I7J0 i I � �' '�fQC) <br /> iM 12 Containers 13 Total 14 1 <br /> 11 US DOT Description(Including Proper Shipping Name Hazard Class and ID Number) Quantity Unit Waste No <br /> No Type Wt/Vol <br /> Q <br /> V a Slate <br /> Z G ,t 1 r �011 <br /> }� �/NWHSi� DiSt�J� (..i Uid 46 5W '/ if Ola O 14 6 -7 e <br /> 04 E b C� State� <br /> R8 A <br /> e, <br /> [ / Zp�� � a rafer <br /> polsovIr <br /> / <br /> v R c State Z <br /> 0 <br /> m <br /> EPA!Other <br /> W d State <br /> Z <br /> w <br /> U EPAI Other <br /> J Additional D c poo s for Materials Listed ,1 (s 1 IC Handling Codes for Wastes Listed Above <br /> q)Sty 4*fAr?�t�d f AbC J!N(/i✓ �+r� Sit,7 S o r a b <br /> w L7J'ufu e0$V-frNY'S — Profflt:*J7 �-lZZ3lp <br /> M c. a <br /> Zfru o l- �5 o 9 te J I ZZ <br /> F'- 15 <br /> n�aSGJp�re[cCiaI rranoNdlingc Instructions an CACdtltipr nteliE InfnCn:aJtor�N 1. �c �zJ �1 04 <br /> LU <br /> J+/ZZ3S0 <br /> J <br /> J <br /> Q 18 <br /> U <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 i <br /> If I am a large quantity generator 1 certify that I 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 the environment OR 1 am a small quantity generator I have made a good faith effort to minimize my waste <br /> U generation and select the beat waste management method that..;(is vai 61e to me and that I can afford <br /> Z <br /> Cw7 rmtedpod Name ipn-lure Month Day Year <br /> _ ! ` <br /> Wlop I 't islIq <br /> W R 17 Transporter t Acknowledgement of Receipt of Materiels <br /> QA Printed/Typed Nsm� Signature i Month Day Year <br /> LL <br /> O S 10 1!11 JS 151P <br /> w O 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> V) <br /> VPrinted/Typed Name Signature Month Day Year <br /> E <br /> Z <br /> [20Facifity <br /> iscrepancy indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in hem 19 <br /> Ty dlTyped NameSignature Month Day Year <br /> DHS 8022 A(1188) Do Not Write Beiow This Line <br /> EPA 8700-22 Bi e GeNF"� v%1-4,, 3, <br /> (Rev 9 88)Previous editions are obsolete <br /> J- <br />