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All nonawelfareAgency Department OS Health Services <br /> W--w-Na.2050-0Q39(Expires 9-3 Toxic Substances Control Division <br /> ur type. (Form designed for use an a 'pitch fypewrlter). ;; Sacrament D,California <br /> UNIFORM HAZARDOUS enerator's US EPA ID No. Manifest 2C..fge 1 <br /> Information in the shaded areas <br /> WASTE MANIFEST i f Dacuritent Nv. <br /> 4- ' i ` ` is not required by Federal law. <br /> I 3. Generator's No a d Mailing Address r-.t <br /> /`i✓'t A. State Manifest Document Number <br /> tai 5/��+ �.•t - t �--{//�- /,. <br /> &8443 <br /> 647 <br /> --,:D4 �L 'ry `^" �'r 1 �` R'.t� B. State Generator's ID <br /> I 4. Generator's Phone t <br /> 5. Transporter t Company Name 6. US EPA ID Number !: C- State Transporter'a D <br /> r. s:��� <br /> N K. ;r '1{ 1f I +�, '✓ D. Trenapvrter's Phone <br /> W 7, Transporter 2 Company Name 6. US EPA D Number !� E. Stele Trensporter's(D <br /> p i+ <br /> p F. Tranaporter's Phone <br /> to <br /> 9. Designated Facility Flame and Site Address 10. ISS EPA ID Number G. Slate Facility's 1D <br /> U �/ l ` ✓V�'' <br /> Ni `� � f * ' �; K.Facility's Phone <br /> it <br /> cc <br /> I! 12. Containers 3. Total 14. (. <br /> D/�o 11. US DOT Description(Including Proper Shipping Name.hazard Class,and ID Number) f Quantity Unit Waste No. <br /> V)� �1 No. Type Wt/Vol <br /> .< a. — }i �, y�tl1t ,-� state <br /> z If <br /> x G r EP /Other <br /> qpN <br /> ID E b. It State <br /> N R <br /> mT EPA/Other <br /> 0 <br /> N <br /> C. State <br /> W EPA/Other <br /> w d. State <br /> VjEPA/Other <br /> W <br /> U J- Additional Descriptions for Materials Listed Above I K. Handling Codes for Wastes Listed Above <br /> Z a. <br /> a. <br /> ,j <br /> W <br /> t�V &I i .► C. d. <br /> Z <br /> f IS, Special Handling instructions end Additional Information <br /> ty <br /> G 16. �} <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 clasaified•packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> b national government regulations. <br /> W <br /> !t 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 /> a to be economically practicable and that I have selected fine 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 gen'erator,I have made a good failh effort to minimize my waste I <br /> } generation and select the best waste management method that is available to me and that I can afford. <br /> U <br /> Z <br /> Printed/Typed Name Signa Month Ray Year <br /> LU <br /> w T 17, Transporter 1 Acknowledgement of Receipt o1 Materials <br /> R ., <br /> Z A Printed/Typed Name". _ _, - Si tur� - i'„y;r Month Day Year <br /> LL <br /> P 18. Transporter 2 Acknowledgement q1 Receip f Materials 1. <br /> WMonth Day Year ? <br /> q Printed/Typed Name rafure <br /> L] E <br /> Z i <br /> 4iI 19. Discrepancy Indication Space <br /> A <br /> i c ) <br /> i i I R <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. i <br /> v :Printedl7yped Name I Signature .l - .•err say Year <br /> DHS 8022 A(It 88) Do Not Write Below This Line, <br /> EPA 8700-22 - - <br /> (Rev.9-86)Previous editions are obsolete. _ <br />