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rurrn AipprOveC1 .JT 10 NO CirctT'......a ka II,.lreb J vu y I Toxic Jucbiaaces Vcalrol Dwision <br /> Please print or type (Form designed for use on efrte(12 Ortel typewriter) Sacramento California <br /> I Generators US EPA ID No Manifest 2 Page 1 <br /> UNIFORM HAZARDOUS Information in the snadetl areas <br /> WASTE MANIFEST L Ala tty�nty�o <br /> 01 U :1 �i 31 s �! LS of is not required by Federal law <br /> 3 Generators Name and Mailing Address A State Manifest Document Number <br /> Ca',—Fa--m Su <br /> CCA 5�5'.. 13 State Generator's ID <br /> L <br /> A GiSnratol' llorieC r^} <']' <br /> 5 Transporter i Company Name B US EPA ID Number C State Transporters lD + U4 14-a <br /> � <br /> Djo1 9 1 a ! I 1 q l { D Transporters Phone (an-) — ��`7 <br /> N <br /> m 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID <br /> to <br /> I F Transporters Phone <br /> Co <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Facility s iD <br /> J Ch mica i a—z vis Mw-a—,a nt r '---C./XaT-Z1 Wan H113 S Mc. m 61AI 61 1 <br /> 11171 <br /> Olc. S::;11ne H Facility s Phone <br /> C1 t 7L r' CA 922'9 C A T O O O 6 4 6 11117 (249} 385-977.1 <br /> SIX' 12 Containers 13 Total 14 1 <br /> 9 11 US DOT Description(Including Proper Shipping Name Hazard Class and ID Number) Quantity Unit Waste No <br /> LOZ No Type Wtivot <br /> C00 a JIF ^dcss Wa�ze Sc2-1 'No's.s. / M E / State <br /> col 1$9 O 1 O ' Y EPAlOther <br /> N <br /> E b stale <br /> of R <br /> o A <br /> m T EPAtOther <br /> v 0 <br /> C4 R c State <br /> 8 <br /> CID <br /> EPA!Other <br /> Lu d State <br /> r <br /> Z <br /> w <br /> U EPA!Other <br /> w <br /> rn J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> Z a. b <br /> I. <br /> a.) soil cormaining pesticides, mTr MD <br /> C d <br /> 0 <br /> >r 15 Special Handling Instruettons and Additional Information <br /> Z a.) Prcxlle # SFO--,T-26270 <br /> 1 FG�.r13te �rro+.B IVa C1.a�>`,:��a-19 & MsP3 rat'r Si�+� -" P-r3T d1 s"�y. <br /> U 16 <br /> J 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 /> d national government regulatlons <br /> X If I am a large quantity generator I certity that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have dete•mmed <br /> Q to be economically practicable and that I have selected the practicable method of treatment storage or disposal eurrentty avadable to me which minimizes the <br /> present and future threat to human health and the environment OR if 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 can afford SAI <br /> Z <br /> uj PrintedlTyped Name CA �E WHIrW 1 TH �S i re I\ i Month Day Year <br /> IM <br /> 'tUPTCY TRUSTEE FOR CAIS.—lFlrlXiGii+iLlsSUPPLY � � � 1Z� c3 4 { 1 <br /> tyi T 17 Tranaporter 1 Acknowledgement of Receipt of Materialsi I <br /> Z <br /> R i <br /> rints <br /> Q A PTyped Name Sign urn Month Day Year <br /> N kk <br /> OPCP l� 1t\n. I i <br /> Lu 0 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> VT Printed/Typed Name Signat re Month Day Year <br /> E <br /> ZR - 7 <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> T <br /> y Pnnted/Typed Name Signature Month Day Year <br /> DHS 8022 A(1/88) Do Not Write Below This Line <br /> EPA <br /> e 88)P2 <br /> (Rev 989)Previous editions are obsolete Blue GENERATOR SENDS THIS COPY TO DCHS WITHIN 30 DAYS <br /> (Re <br /> I To P 0 Box 400, Socramento, CA 4:812 C.,00 <br />