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State of California--Health and Welfare Agency Department of Health Services <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 efite(f2 pitch typewnter) Sacramento California <br /> F3G-enerator <br /> NIFORM HAZARDOUS 1 Generator's US EPA ID No Document t 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST C C 0101 Q 2 !- Q8101 1 Q Q ni is not required by Federal law <br /> s Name and Mailing Address A. State Mande Document Number <br /> M FAM SUTLY C/O CAS STH(TRUST"�©. BOX 280 DAVIS, CA. 95617 B State Generators 16 <br /> 4 Generator a Phone } <br /> 5 Transporter 1 Company Name a US EPA ID Number C State Transporter's ID <br /> LO <br /> amiurnw. MICKIM IC 1A `,( L C. 2 0 Transporter's Phone <br /> m 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter's E <br /> 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 /> Co J <br /> CKWIM WAM Ii Factlity'a Phoria <br /> coo <br /> 35251 OLD S>I�L� $D. <br /> Co zEXAM CM IrAw 9 <br /> 12 Containers Ta a f <br /> 11 US DOT Description(including Proper Shipping Name Hazard Class and tD Number) Ouantity Unit Waste No <br /> M J No Type Wt/Vol <br /> U a State <br /> KG 611 <br /> Co � N WARD= NAM SOLID A.O.S. ORK-9 NA 9189 ePA/Other <br /> 001DT00018 Y 006I <br /> E b State <br /> cm R <br /> T EPAIOther <br /> le 0 <br /> cm <br /> Q A c <br /> Stele <br /> m <br /> EPA/Other <br /> LU d State <br /> z <br /> U EPA/Other <br /> W <br /> J Additional Descriptions for Materials Listed Above K, Handling Codes for Wastes Listed Above <br /> a b <br /> W=v SOIL, ALS@[, (MMM) COUANDMM t WITS <br /> D.D.T., D.D.B.s D.D.D.. (T.D.E.) a d <br /> J <br /> Q <br /> Z <br /> Q 15 Special Handling Instructions and Additional Information <br /> s WEAR PROM PROTEC21W FAWLelow 9M HANDLIN CM PWF= # J 26270 <br /> J <br /> J <br /> Q 18 <br /> U <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 /> d national government regulations <br /> u) <br /> Q 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 /> p 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 ern a small quantity generator I have made a good faith effort to minimize my waste <br /> Q generation and select the beat waste management method that is available to me and that I can afford <br /> Z <br /> Pnnted/Typed Name �Qy��t..� C� '"� Sign tura Month lay Year <br /> W T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> CA Printed/Typed Name Signur Month Day Year <br /> N <br /> LL S <br /> W 0 18 Transporter 2 Acknowledgemdrif of Receipt of Materiels <br /> UT Panted/Typed Name Signature Month Day Year <br /> z <br /> E <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I r2(0) Facjlgty Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in item 19 <br /> T <br /> y d/Typed Name Signature Month Day Year <br /> DHS 8022 A(1/88) Do Not Write Below This L1ne3auaEPA 8700-22 G:rIERATCR :E\1,c COPY -�� ,CFS n T-ttii 30 DA�i� <br /> (Rev 9-88)Previous editions are obsolete 7o P 0 Sox 100, ^-ccs amento ori ?5$ 2 040 <br />