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cal�i QCNK.--� <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 side(f2 pitch typewriter! Sacramento California <br /> 1 Generator s US EPA 10 No Manifest 2 Page t <br /> UNIFORM HAZARDOUS Information in the shaded areas <br /> WASTE MANIFEST C 3 { g :pi+� q oc� p� <br /> I A C t7 U of is not required by Federal law <br /> 3 Generators Name and Mailtng Address A State Manifest Document Number <br /> DAv=a, CA <br /> 8 State Generator's 10 <br /> ^Z9 �aY6_a; <br /> Generals thane ^ <br /> O_�) r. . <br /> aj 5 Transporter t Company Name 8 US EPA 10 Number C State Transporter s 10 00e5 VQ to <br /> in q <br /> wI C1 A r] 01 61 21 `1 — ' 1 D Transporter s Phone V80--;) 80-5ZZO <br /> 10 7 Transporter 2 Company Name 8 US EPA 10 Number E State Transporter s ID <br /> to <br /> F Transporter s Phonepsd��z(� <br /> to <br /> 9 Designated Facility Name and Site Address 10 US EPA 10 Number G State Facility a 10 <br /> J C7.�'ri Uel WdS we i s'Zca� :c:? J t:G./Neztlt_man H Ll?.: x Ac. Q Q © 6 6 T 7 <br /> �(a <br /> J-721 Old RGGC: H Facility s Phone <br /> CA 922:,9 O A O Q Q os 4 O 1 / (LOG) 286=9711 <br /> 12 Containers 13 Total 14 I <br /> it US DOT Description(Including Proper Shipping Name Hazard Class and 10 Number) Quantity Unit Waste No <br /> No Type Wt/Vol ' <br /> C0CJ a State <br /> C0Z F,az rcCu,, we--t a N7CS. l dR - y <br /> cot: N IIA9189 EPA,Other <br /> ��' E b O 1 z r— State e <br /> N R <br /> O <br /> cc m y EPA/Other <br /> Q 0 <br /> v R G <br /> State <br /> a <br /> m <br /> EPA/Other <br /> LU d State <br /> Z <br /> U EP 41 Other <br /> LU <br /> z <br /> J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> e b <br /> a. Soli m-iewi3v.nG pest$clres, :., DCD <br /> c d <br /> z <br /> 0 <br /> != 15 Special Handling Instructions and Additional Information <br /> Z a. P rOzale # SFO-J-246270 <br /> Wear aD-,ropriat.,a -protects vT-- cl ct-=S; and r^si izator wtian handling- <br /> U t E) <br /> GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> 1 and are classified packed marked and labeled and are m all respects in proper condition for transport by highway according to applicable international and <br /> Wnational government regulations <br /> M If I am a large quantity generator I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> d 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 It I 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 available to me and that I can afford <br /> Z <br /> LU PnntadlTyped Name CATHR=E W11MRTH . Sigr(}ture � Month Day Year <br /> Lu BnTA,YUPCYLTSTEE FOR CAL-s�ATii4 SUPPLY +[f 44 <br /> i <br /> W T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> 2 R <br /> Q A Pnnted/Typed Name Signature Month day Year <br /> N /l <br /> `L S ��t I�GG�N S � <br /> O P <br /> LU 0 to Transporter 2 Acknowledgement of Receipt of Materials <br /> UR Printed Name Signature Month Day Year <br /> E <br /> 2 <br /> 19 Discrepancy tndocation Space <br /> F <br /> A <br /> C <br /> t <br /> .1 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 Prrnted�Typod Name Signature Month Day Year <br /> DHS 8022 A(1188) Do Not Write Below This Line <br /> EPA 8706-22 <br /> (Rev 9 88)Previous editions are obsolete Blue GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAIS <br /> To P 0 Box 400 Socramentc CA 4812 04CO <br />