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Please print or Noe. fFcrm designed fnr nce nn rhap n -tea hi h, e.,,..r <br />:FA Form 8100.22,A(Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />ZARDOUS WASTE MANIFEST <br />- - "' ' <br />21. Generator ID Number <br />22, Page <br />Form Approved. OMB No, 2050-1039 <br />23. Manifest Tracking Number <br />ntlnuatlon Sheet) <br />CA2890090002 <br />5 <br />006870331 J.iK <br />FGeneratoesame L 3'Mreric LM?I7TIOr_ h!1 tonal L3bOr'ai0i f `:it2 'dam for PIGISA. �y a <br />Lige Mor. CA. 94551 <br />25 T enspoder Company Name U.S. EPA ID Number <br />26. Transporter Company Name US EPA ID Nun -be iE <br />HEALTH Di-ER",RTMENT <br />27a. <br />V U S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />28, Contaicers <br />H%1 <br />and Parking Group (if any)) <br />29 Telal <br />29 Tol y <br />30. Unit <br />30.�it Unit <br />31 ';Paste Codes <br />Flo. <br />Type <br />35. Pion-IRCP.A hazardous waste, solid (bum Pit ash) (S.J95-2554) <br />1s1 <br />1 <br />DF <br />105 <br />P <br />38. Non-RCRA hazardous ,vante, Mid (debds contarninated with <br />petroleum hydrocarbons)(DOP0044-1) <br />223 <br />1 <br />DM <br />80 <br />p <br />37. Non-RCRA hazardous v,raste, solid (debds contaminated with <br />petroleum hydrocarbons) (DOP0044-1) <br />223 <br />3 <br />DH <br />559 <br />P <br />0 <br />38. )lion-RCP.A hazardous waste, solid (dried paint) (D01`0120 11 <br />231 <br />w <br />o <br />DF <br />943 <br />P <br />'39. Non-RCRA hazardous caste, solid (ernpty drum last contain <br />�,otlolaurrf h;'droca bons) (DOP0047-1) <br />sit <br />I <br />DM <br />90 <br />P <br />40. `!on-RCP.A hazardous vvaste, solid (empty drum last contained <br />petroleum hydrocarbons) (DOP01347-1) <br />sit <br />1 <br />DM <br />40 <br />P <br />41. Non-RCP.A hazardous •:vaste, solid (errvt,, do-im !a7 contained <br />petr.!eumh;dre.abcns) <br />_12(DOP004?1 <br />7 <br />DM <br />333 <br />P <br />42. Non-RCP.A hazardous'vuaste, solid (empty dr -um) (DOP0047-11 <br />s13 <br />1 Lit <br />1 <br />16 <br />P <br />43. Non-RCRA hazardous vvaste, soiid (err -Pty drums last contained <br />petroleum hydreca3tons) (DOP0047-1) <br />512 <br />2 <br />Dt3 <br />80 <br />P <br />44 Mon-RCRA hazardous•,aaste, _olid (grease) ( OR0037-1) <br />221 <br />1 <br />DH <br />17 3 <br />P <br />32 Special Handling Instructions and Additional Information <br />33 Transporter Ackno•rdedgment o1 Receipt of ?dalenals <br />LLJ <br />Printed/Typed Name Signalare Month Day Year <br />C) <br />0 <br />CL <br />Z <br />34. Transporter _ Acknordedgment of Receipt of h,latenals <br />Printed Typed Name Signature Month Day Year <br />f— <br />} <br />35, Discrepancy <br />N <br />J <br />U <br />Q <br />LL <br />ui <br />W <br />a <br />36 Hazardous Waste Report Management Method Codes (i e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Z <br />(D <br />LL, <br />0 <br />F- <br />:FA Form 8100.22,A(Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />