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'19 <br />Farm Of roved M Health and Weller( Expires See Instructions on Balk of Page Form Approved OMB No. lin-39 (Expires -30-91) o_ J 6 Department of Health Services <br />Pleees orinl or rvna c.,..., w..e....w .... ..__ __ _.,� _,._.. .. and FlDDI of ] Toxic Subatancen Cnnbnl niw.u... <br />)HS 8022 A <br />IPA 5700-22 <br />Ray. 6-e9) Previous editions are obsolete: <br />uO Not Write Below This Line <br />UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest <br />Sacramento, California <br />2, Pape 1 — <br />• WASTE MANIFEST n Document No. <br />Inlormalion in the shaded areas <br />of is <br />rJ <br />3. Generelor'a Name one mailing Address <br />I not required by Federal law. <br />en`,�z.-�., <br />A. Stale Menlleel Docum 1 u bo <br />�� <br />ISE 6V 2 (� ''C <br />otw V A . 460P � `57 UI °z' .160 • e)c,?5TOa <br />65480 <br />8. Slate ()enerelor'e ID <br />�7 <br />.. Generalor's Phone / ) 6,P 41 �, q e a -77 7A <br />0 <br />6. Tranep otter 1 CompelsNeme e. U9 EPA ID Number <br />C. Slate Transporter's to <br />aZ <br />0 <br />]. Treneporter 2 Compeny Neme e. US EPA ID Number <br />aL <br />D. T,sa.pen.l•. nonek&Y'golf <br />E. SIH( Treneporlei a ID <br />m <br />1 1 1 1 1 1 1 1 1 1 1 <br />Traneporter'e Phone <br />9. Designated Facility Name and Silo Address 10. US EPA ID Number <br />G1356AI l6"1I?0Me14TA1— <br />G. State FaviaID <br />END OF C6[NtwtE0?C1'91. DR. <br />afl�.Yll 7Z <br />BH KFIZSFIE D <br />H.FacIlllyePhone <br />z <br />C/#. 93 e P IC161DI9 PO P� 130 l -77 <br />S <br />/:QL..afity <br />y11. <br />US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />la. <br />NON RCRR HA�RM15 LIQUID W;`1SS-mFG3 <br />No. <br />Type <br />Unil <br />WI/vol" <br />Waste No. <br />IEPA�Olh3 <br />N <br />E <br />b. <br />v R <br />A <br />o T OR <br />nEPAIM <br />c. <br />d. <br />stele <br />1 <br />LPA/Other <br />j <br />J. Atl+d!Nbnal Descriptions fair Meplar/i�ale Listed An... <br />CX1 <br />K. Hendnse (aa. ler WeHee <br />a. <br />.tatl ova <br />b. <br />� � <br />': <br />SITE' /9DD�ESS ^ X39 S. SToCK'To�( iUE': <br />d. <br />d. <br />RIPON I` CH. 1?5366 <br />15. Special Handling Instruction, and Additional Information <br />I <br />0 o d 5 Aeo S l �e <br />le. <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping nems <br />and are classified, packed, marked, and labeled, and are In all respects in proper condition for transport by highway <br />nolional government regulations. according to applicable inlarnalionel and <br />Il l 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 />to be economically practicable and that l 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, If I am a small quantity generator, I have made a good lallh effort to minimize my waste <br />generation and select the beat waste management method that to available to me and that I can afford. <br />Printed/Typed Name Signet a Month Day Year <br />* <L <br />T <br />R <br />17. Transporter 1 Acknowledgement of Receipt of Materiels <br />A <br />N <br />S <br />Printed/Typed NeNme <br />O ams Sign a Month Day Year <br />PO <br />R <br />19. Transporter 2 Acknowledgement of Receipt of Materiel( <br />T <br />E <br />Printed/Typed <br />sped Neme <br />Signature Month Day Yeer <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />T <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered b Is manifest except as ole n It.. 19. <br />y <br />Printed/Typed ems <br />(/ I45 <br />tCLI <br />Sl9nalure <br />_ yv _ / _ M�r e Y in, <br />)HS 8022 A <br />IPA 5700-22 <br />Ray. 6-e9) Previous editions are obsolete: <br />uO Not Write Below This Line <br />