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g <br /> I Momia—Hth and Wey re Hcy: s; <br /> Department of Health Service <br /> ow§� MB X039(Et�T 90.91) ,.;5@21nsfi9lCltonso page 6.' Toxic Substances Control Progran <br /> 1(� <br /> deAgnedfa-Tzse on elite(12-pRcr wn'er) ' ���I `�� Sacramento,ColBomi< <br /> (FORM HAZARDOUS Generator's l/5 EPA ID No. Manifest Docy�G No. 2.Page 1 Norms an in the shaded areas <br /> WASTE MANIFEST l`: l 7 tj ! 6 i 2 1 I 1`J er I is not required by Federal knv. <br /> 3.Ggnerotofs Name and Mailing Address A stat.N SnRo t u.rb�f Namhcryry <br /> N,.k;,-,ice .:: . <br /> a.Generators Phone ; Z",i1 <br /> 5.Transporter l Company Name o.US EPA ID Number �+5�. C.5tcte Tr,�;ixtrtes l� <br /> y' I` I /II/ ITL I/ N li D ���SF*: <br /> 7.Tnonporter2Company Nome 8.US EPA ID Number E .`cY,o Tr0,,ortors ID <br /> 1 I I i I I I I I I I F ln-rarx*'br'S rTww <br /> vDNa e d 10.115EPAIDNumber G ac <br /> Stdo F98ys ID <br /> C � 14'I <br /> 1 1 1; 1 r I I <br /> ,e <br /> r <br /> d Al1 <br /> 11.US DOT Description(including Sh 'ng Name,Hazard Class,and ID NumbeO 12.Contain»n 13.Total 14. <br /> Unit <br /> No. T Quant' Wt/vol f Jwmte'v„mbbr <br /> -J' f a abOVeRTent Ing COr�atlon y stale <br /> Q 1`l: r ;, -n k?Ilf(i 1Ya; certifte$ « _ <br /> V G f tltle(f by rete Qnr s , �S/ -rOi£ th ePAI01'or <br /> RCCtf c <br /> •"� E MV -� n <br /> coZ N SI Wag/W �r , j iiGIU <br /> b. <br /> 0O E ri, ah,}CFR?,5, of (J�rT� sry2j:=r i. StoJg <br /> Witty T,. <br /> LL R 3(C) } <br /> me reC ; yr 1;lraUal,i: t? T <br /> My A ��iar aNvftsj : c - @6eflP.rd i. +'r. 3 ; �,,o <br /> r..= o s }ons of 40CFFF 2,66I tea SubpaC. <br /> rt <br /> accordant, orae <br /> a-•1 R <br /> 0) PE, Part p, <br /> EPA/Other <br /> 3 - =Uh9 <br /> d ATlOn mob ' <br /> � I I I I I I 1 <br /> Q •� <br /> o J AtldRorbl Desclatals fMMdferfak._Kted K Handling Codes torWmfes tiled Ahove <br /> "°°"� a 5 <br /> c <br /> w l <br /> U 75.Special Handling Irufrucfiom and AddRorol IrAoenatbn <br /> w <br /> o 0 32 il <br /> c 14g6A <br /> J <br /> Z <br /> id.GENERATORS CERTIFICATION: 1 hereby declare that the contents otitis conigrmenF are forty and accurately described above W proper shipping name and are ckus'red. <br /> re <br /> O packed,marked,and labeled,and oin all respects in Propercondilion for transport by highway according to applicable International and national govemmerst MgWalions. <br /> Qff I am a large quonfiy generator.I certify,that I have a Program in place to reduce the volume and toxicity of waste generated to the degree'I-have detertnkred to be <br /> • Z economic-ally, m <br /> practicable and at I have selected the practicable method of treatment,storage,or disposal cunently available to me which minkn¢es the present and future <br /> w final to human health and the en vionmeM:OR.M I am a sm,N quantity generator,l home mode a good faith effort to minMee my waste generation and select the best waste <br /> rF morogement method thad is available to me and that I can afford <br /> -[ 2J <br /> Q PrtHed/fYPed Name Signature MDay Year. <br /> C ,T 17.Transporter l Acknowledgement of Receipt of Mail <br /> O R Printed/Typetl Name Signalgre - month �y Y9or <br /> Z S <br /> > ' [/ <br /> wPO 18.Tran Herz Howie ement of Receipt of Materials <br /> R Printed/Typed Name Signature <br /> T Month cry Yea <br /> a <br /> LL E <br /> Q P 19.Discrepancy Indication space <br /> U A <br /> Z C <br /> 1 20.Facility Owner or OperatorCedificalion of receipt of h=rdous materials covered by this manifest except as noted In Bern 19. <br /> T Printed/Typed Nome I Signahrm"T Month Day Year <br /> y LZ <br /> 1/1�/ <br /> DO NOT WRITE BELOW THIS UNE. <br /> DH58022A(12/90) Yellow: -..:'TSDF S41DS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> EPA 8700-22 <br /> g'. <br />