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State of California-Health and Welfare Agency <br /> Department of Health Serves, <br /> See Instructions on b, of page 6. Toxic Substances Control Piogru <br /> Please print or type. Form designed/or use on edte� ,h typewriter). <br /> Sacramento.Collorn, <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Man fest Document No. 2.Pape 1 IrNorrnation in the shax:A areas <br /> WASTE MANIFEST l I l `I 'I °sl I I ''I I I I I I or l not required by Federal kaw. <br /> 3.Generato Name aril Mailing Address <br /> 4: m <br /> A State Man,(esT Document Nubet•T <br /> � ~� w 1 <br /> r B.Stale Crenefator's C <br /> 4.Generators Phone( ) <br /> 5.Transporter 1 Company Name 6.US EPA ID Number C State I(ansporter's ID <br /> f i! T 1•..:i Y,7 L 1 1 1"I.1 I ' I•� I .� I" / I I 1 D, Trarisportef6 Phone 1 .. <br /> 7.Traruporter�2 o t`y Name 8.US EPA ID Number E.State Transporters ID y f', <br /> � 1 I . ,l >-� <br /> !r _ ( <. �" ri1 r: I F.Trarn e(sPhone <br /> 9.Designpted Faciity Namti and Slt�Adc)res� 10.US EPA ID Number G.State IR <br /> I,..o Y t4� y 7 <br /> 1 3)..• �'{ .:aiy .SJ �:Xt --`.:i"�t�l•i <br /> 00 .H.Facilrty'3Phone <br /> 1. I II I ' I ` I I I ' I I <br /> 11.US DOT Description(including Pro 12.Containers 13.Total 14.Und <br /> P nig per Shipping Name,Hazard Clan,and ID Number) <br /> _ <br /> a. No. T Quant MN01 I.Waste Number <br /> r�:� L V ,'U V aJ i. ti� J <br /> IState <br /> U G IYl� a 1 7 J <br /> N b I I " ! I ` I ✓1� U A/'"..her _. <br /> Ll- <br /> N O E stare <br /> R <br /> Q <br /> A <br /> z T C. I I <br /> 41;�T = 0 Stale <br /> t—i 3 R <br /> Z' <br /> EPA/Othe( <br /> N I I I I I I <br /> d. <br /> m State <br /> C <br /> V <br /> N <br /> V <br /> d I I <br /> J.Additional Descriptions for Mater of Listed Above K.Handling Codes for Wastes Listed Above <br /> 4. Q b. , <br /> c f > <br /> Z <br /> w <br /> U 15.Spec�I�rxfl�7r�t��pt�Q�ll�ddr�p�1R(�r��rjl it J�}1ii -- <br /> w <br /> z +�+��i u:irl 1 i� r,;;; [.1 I YL'.I♦,:1�1.tLlry lr iJl�Ti��T �F �:►v�jt,J�i-�4=i�y <br /> t►:.l�LTv�I ul� b-iiLK►it;,11i(,V i U,%1 AL( <br /> U) <br /> Lu <br /> c <br /> J <br /> Q 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are cksssifod. <br /> Z pocked,marked,and labeled,and are In all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> 0 <br /> QIf 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 have date mined to be <br /> Z economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> w threat to human heolth and the environment;OR,R I am a small quantity generator,1 have made a good faith effort to minimize my waste generation and se <br /> k�ci the best waste <br /> = morx�gement method that is available to me and that I can afford. <br /> r- <br /> J <br /> -' Printed/Typed Name <br /> U Signature <br /> Month pay year <br /> a <br /> V) <br /> c T 11.Transporter 1 Acknowledgement of Receipt of Material <br /> O R Printed/Typed Name Sjpnature Month L1oy Veo, <br /> y A <br /> U N <br /> Z 5 <br /> C0 18.Trani iter 2 Acknowledgement of Receipt of Material L — <br /> w R Printed/fyped No <br /> Uj T Signature - <br /> w �/ / Month Day Yam <br /> ( I <br /> Q F 19.Discrepancy Indication Space <br /> ;LitI <br /> 71- <br /> U A <br /> Z C <br /> L20.Facility Rl'Owner or Operator Certification of receipt of hazardous material covered by this manifest except as noted in Rem 19. <br /> T Printed/Typed Name Signature <br /> Month Day year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DHSEPA 8700-22 90) Green: HAULER RETAINS <br /> EPA 8100-22 <br />