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Form Approved CMB No 2050-7039(Expires 9 d0 91) i ox c audstancas Controi Division <br /> Please print or type (Form designed for use on elite(12 pitch typewriter) Sacramento California <br /> UNIFORM HAZARDOUS 1 Generator s US EPA 1D No Manifest 2 Page 1 <br /> Document Na lnformahon m the shaded areas <br /> WASTE MANIFEST at is not required by Federal law <br /> 3 Generator s Name and Mailing Address A Stats Mallfe Document Number <br /> Cal-Pam Supply, c/o CAtberim Whitv=th <br /> 8131876 --- <br /> l <br /> P.O. B= 280, Da i.S, ® 95616 t3 State Generators <br /> 4 Generators Phone <br /> 5 Transporter 1 Company Name 8 US EPA ID Number C State Transporter's ID Q <br /> 41+� I I D Transporter's Phone <br /> N <br /> m 7 Transporter mparty eine 8 IM EPA TD Number- E State Transporters k%5) 50-4035 <br /> a F Transporters Phone <br /> m <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Facility's ID <br /> �¢ EW EavircrImmital �D <br /> Q � K Facility s Phone <br /> co Z am q4llfff 1421A In I Q In 1417171 1191 A, (4 543--m 9; <br /> 0 12 Containers 13 Total 14 { <br /> co 9: 1 t US DOT Description(Including Proper Shipping Name Hazard Class and ID Number) Quantity Unit Waste No <br /> j No I Type wt/vol <br /> H U a IdLkIF L e'sG G.m Stat 1 - <br /> CO E Q11f Mii3 R01111lated WaSte OMIT -f> EPA/Ohio, - s, <br /> y N rc r z <br /> } E b State - <br /> nj R - <br /> T EPA/Other � - <br /> o , <br /> R C $t9lB - <br /> O rte,AlQtherryy!_�{v i�'a'•''}Y <br /> CID EP � - <br /> w d. State <br /> Z <br /> U EPA/Other ~ <br /> W -- <br /> x Z J-Additional Descriptions for Materials ListadlAbove, r _ _ K Handling Codes.for Wastes Listed Move <br /> b _ <br /> C15. Special Handling Instructions and Additional inform coir <br /> pacotective clothingz040' 611;o N :A <br /> f tai to <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 <br /> M 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 /> p to tae 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 emnronment OR if I am a small quantity generator I have made a good faith effort to minimize my waste <br /> Z generation and select the beat waste management method that is available to me and that I can afford <br /> O Printed/Typed Name Sign ure Month Day Year <br /> Lu Cat> it�e il&itz=th as � <br /> 2 . . <br /> " <br /> -rus .17 Tra s <br /> Z. Printed/Typed Name Sign a Month Day Year <br /> (>- <br /> = sa 1I!? s ✓j 1 <br /> .4!1u p 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed! ed Name <br /> T Printed/Typed Signature <br /> Match Day Year <br /> E <br /> "S <br /> t r 19 Discrepancy Indication Space <br /> fr <br /> A r <br /> C <br /> r L <br /> ' f 4 20. Facility owner or Operator Certification of receipt or hazardous materials covered by this mamfoat except ea noted in Item 19 <br /> T <br /> Y Prfrited/Typed Name Signature Month Day Year <br /> t: r Dt IS 8072 A(visa) <br /> ' EPA 8701 Blue Not Write Below This Line Blue GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (Rev 9'88)Promos editions are obsolete To P O Box 400, Sacramento, CA 918120.100 <br /> - <br /> � r« <br />