Laserfiche WebLink
rarm Approveo L�Me No �Ot)0 -0-q&J iMxPlres a aU 9 Q Taxis Cunszances Conirgl Division <br /> Please print or type (Form designed far use on elite(f2 pitch typewriter) Sacramento California <br /> UNIFORM HAZt Generator s US EPA ID No Do utr3�pt Mand t 2 Page 1 <br /> ARDOUS o. Information in the shaded areas <br /> WASTE MANIFEST 0 Lr t✓ of is not required by Federal law <br /> 3 Generators Nam*and Mailing Address A State Manifest Document Number <br /> Cal--Fa= StMly, 'c% Catblerine Whitralorlrb, 88131875 <br /> P.O. Hag 280 8 State Generator's ID <br /> 4 QWgiSl Pe&( 95016 ,, <br /> ¢i6 Transporter t Company Name 8 US EPA 10 Number C State Transporter s IDKe <br /> Q4 <br /> N <br /> I I D Transporter a Phone <br /> m 4- MIMI 9,99 3229 <br /> 7 Transporter 2 Company Name 8 US &A-113 Number E State Transporter's ID <br /> g F Transponees.Phone <br /> as <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number a State Facility s ID <br /> < [weir 11 Waste 143M Mac. Kttlemn 8131 Par— .01;k1,Pln1nlnlr,141651 31 1171 <br /> U 3321 Qld SkyLine road H c1 h ne <br /> CO 2 � City, C& 93239 <br /> 1.4 CC 12 Containers 1 Total 14 L <br /> � OW 11 US GOT Description(Including Proper Shipping Name Hazard Class and 10 Number) Quantity Unit Waste No <br /> �•I <br /> No I Type wtivnt <br /> U a State <br /> CO z G H=Wdioua -MEW S011d WS.1 CRI-V NA9189 <br /> t�F E ; D T Q O Q I Y EPA/Other <br /> }i N <br /> E b State <br /> C4 R <br /> A <br /> m T EPA10ther <br /> IT o <br /> V R c State <br /> 8 <br /> m <br /> EPA/Other <br /> F d State <br /> Z <br /> W <br /> U EPA/Other <br /> W <br /> m I J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Ltated Above <br /> Z <br /> O a tr <br /> Id art Soil cmtaining nesticides, Mr, EM <br /> C d. <br /> 1 _ <br /> O <br /> C15 Speciai Handling Instructions and Additionai Information <br /> Z Sro-'s <br /> W a. Profile # SFM► 2110 <br /> iE <br /> Wle r a__VrLite jaL teCtiVe Clotbing & reg rator lftagt bandfpg. <br /> U 1B <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 /> UU national government regulations <br /> M If I am a large quantity generator I certify that I have a program in piece to reduce the volume and toxicity of waste generated to the degree I have determined <br /> O to be economically practicable and that I have selected the practicable method of treatment storage or disposal currently evadable to me which minimizes the <br /> } present and future threat to human health and the enwronment OR if I am a small quantity generator,I have made a good faith effort to minimize my waste <br /> U generation and select the best waste management method that is available to me and that I can afford <br /> z <br /> W Printed/Typed NameSign re Month Day Year <br /> w CATHr'"RINE WK WORTH AS <br /> LUlall <br /> T 17 Transporter 1 Acknowledge ant of Receipt of Materials 5 t <br /> Z R 1 <br /> a A Print !Typed Name 11T <br /> re Month Day Year <br /> N <br /> W S \ <br /> O P r <br /> W0 18 ransporter 2 Ac nowledgement of Receipt of Materials <br /> TPnntedlTyped Name Sagnrture Month Day Year <br /> E <br /> Z_ <br /> 19 Discrepancy Indication Space <br /> s 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(It 88) Do Not Write Below This Line <br /> EPA 8700-22 Blue GENERATOR Sc"ICS THIS COPY TO DOHS WITIyMN 30 DAYS <br /> (Rev 9.88)Pramoue editions are obsolete <br /> To PO Box 4130, Sacramerto, CA 9_e <br /> R12-0d04 <br /> I � <br />