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Form Approved OMB No 2050-0039(Expires 9 30 91) Toxic Substances ControlDivision <br /> Please print or type {Form designed for use on elrte{t2 pitch typewriter) Sacramento California <br /> UNIFORM HAZARDOUS 1 Generator s US EPA ID No Manifest 2 Paget Information m the shaded areas <br /> WASTE MANIFEST aCument No required by Federal law <br /> of is not <br /> 3 Generator s Name and Mailing Address A State Matniest Do m nt�a bei r�n <br /> V 6 B State Generator's ID <br /> 4 Generator s Phone <br /> 5 Transporter 1 Company Name 8 US EPA ID Number C State Transporter s IDto <br /> r I!l. rn In I gi : � - ���C`I - I i D Transporter s Phone <br /> 'n 7 Transporter 2 Company Name a US EPA ID Number E State Transposer s ID <br /> to <br /> a I I F F Transporter s Phone <br /> m <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Facility s ID <br /> I z-zt . M-ranag�:c, Tic/��ietClsm n Failz Fes. <br /> � m L 1 <br /> a �" 3.1.:E: Rca�. <br /> U .r Gi Q�u w..x' H Facility s Phone <br /> C0a Kertii man C3.-c;-r, CA S32 9 <br /> C=?� e c 6 -117 209) 386-9711 <br /> 12 Containers 13 Total 14 I <br /> �1� 11 US DOT Description(Including Proper Shipping Name Hazard Class and ID Number) Quantity Unit Waste No <br /> Iia No Type Wt/Vol <br /> CK)U a State <br /> _ G 'ria= -dcus NtSte Sc31G NOS. /OR►Ni. - E <br /> N C I v EPAIOther <br /> E b <br /> CCL <br /> Co R State <br /> o A <br /> W T EPA/Other <br /> IT O <br /> T R c State <br /> m <br /> EPAIOther <br /> W d State <br /> Z <br /> U EP v f,)ther <br /> z <br /> w <br /> to J Additional Descriptions for Matenals Listed Above K. Handling Codes for Wastes Listed Above <br /> z <br /> r}�` a b <br /> c. Sail �.l'7t2'i:3iIlinG --pesticides, IJLYz^, <br /> c d <br /> Z - <br /> 0 <br /> H 15 Special Handling Instructions and Additional Information <br /> Z 2�, ryf lie Y Sr"f)-J-2527(3 �b L'1V V 2.q o <br /> Lu - <br /> 2 <br /> To r ap..rc_rlate 1=ctactive CICt'dr-} andresPl.-atcr Tt1��2>;n 'bier= <br /> J <br /> J <br /> Q 18 <br /> 0 <br /> GENERATOR'S CERTIFICATION I thereby declare that the contents at this consignment are fully and accurately described above by proper shipping name <br /> _l and are classified packed marked and labeled and are in as respects in proper condition for transport by highway according to applicable international and <br /> Q national government regulations <br /> w <br /> ¢ It 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 /> 0 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,if I am a small quantity generator I have made a good faith effort to minimize my waste <br /> 0 generation and select the beat waste management method that is available to me and that I can allord <br /> LU Printed/Typed Name Shgry}turd y Month Day Year <br /> CAT3�.'"RL*TE H$ITrn+ORT'd AS <br /> wT 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> ZA Printed/Typed Name Si urs Month Day Year <br /> +.r <br /> U. sYh� ►.1 Qom , l <br /> P <br /> w Q 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> UT Printed/Typed Name Signature Month Day Year <br /> E <br /> Z R <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 Printed/Typed Name Signature Month Day Year <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 NITHIN 30 (JAYS <br /> To P 0 Box 400 Sacramento CA 95312 CA00 <br />