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'^ State of Ghfomi.—Health and Welfare Agency See Instructions on Be of Pape 6 Department of Health Services <br /> F Form Approved OMB No.2060-0039(Exyjres 930 - and FfOM OI P +7 Toxic Substances Control Division <br /> Pte' '. r type. Fgrm designed for use on a Vl%r2`-pl�l.h typewriter). Sacramento,California <br /> UNIFORM HAZAPDOUB Generator's US EPA ID No. ManifestI2. Pelta t Information in the Metled.rasa <br /> ...T nt No <br /> WASTE MANIFEST < 1 of •not required by Federal taw. <br /> 3. Generator'°Name and Mailing Addre 3 A. Stale atonitoM Dorwment Member <br /> k (i ; r ^7 <br /> �� n , <br /> B. State Generator's D <br /> 4. Generator's Phone C <br /> 0 5. Transporter 1 Company Name 6. US EPA ID Number C. State Tranaporler'e <br /> n: i ...� r G ':;ICI;�.r L. r. J .J ✓ / L D. Transporter's Phone <br /> m 7. Transporter 2 Company Name 8,. US EPA ID Nurgber E. Stale hansportda y <br /> S �i F. Trenaportets Phone <br /> m <br /> 9. Designated Facility Name and$Xe Address 10. US EPA 10 Number O. 9Lta1FiF <br /> "'T 3 i L is 7 <br /> J I <br /> Y s ) <br /> U H Facility's Phpns <br /> '4 <br /> Z -14.y�� <br /> 1� z <br /> TV ¢ 12. Container. 13. Total <br /> Unit tt <br /> O Quantity nWash No. <br /> ti 0 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) No. Type W nit <br /> J State q <br /> l..'Z_ G �') EPA/ <br /> (y.� E / a ) ( 3 <br /> N ) <br /> (-;; E b. auto <br /> 6j R <br /> �'•/2 A EPA/OIMr <br /> m T <br /> a O State <br /> a R C. <br /> m <br /> EPA/Olher <br /> w <br /> d state <br /> Zz <br /> w EPA)gMr <br /> U <br /> N J. Additional Descriptions lar Materials Lifted Above K. Handling Cortes far Wutq Ltoted Above <br /> O / K •.. a. rq. II. <br /> C. d. <br /> Q_ <br /> 15. Special Handling Instructions and Additional Information <br /> Zz e <br /> J l <br /> J <br /> < 16. <br /> U <br /> GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully andI accurately described above proper shipping name J end are classified,pecketl,marked,and labeled,.ntl are in all respects in proper condition for transport by highway according to applicable <br /> icable International and <br /> G national government regulations. <br /> y <br /> degree I have determined <br /> If I em a large quantity generator.I certify that I have a program in place to reduce the volume and toxicity of os ate generatedtlyavailable <br /> to the eg <br /> O pr be economically threat <br /> to hu and that I have selected the practicable method of treatment,storage.or have <br /> disposal currently faith effort <br /> t me which minimizes the <br /> present and future threat 10 human health and the environment;OR,it I am a small quantity generator.I have made a good faith eXori to minimize my waste <br /> > generation and select the beat waste management method that is available to me and that I can afford. <br /> 2Month Day Year <br /> W Printed/Typed Name Signature <br /> w <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> w R <br /> A Printed/Typ itme Signature Month Day Year <br /> N {� <br /> ULS ! sr <br /> P - 14 18. Transporter 2 Acknowledgement f Receipt of materials <br /> 0R Month Day Year <br /> T Printetl/Typed Name Signature <br /> U E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> � C <br /> i I <br /> L <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materiels covered by this manife16 except as noted in Item 19. <br /> i T Si nature Month Day Year <br /> y Printed Nae ° <br /> DMS 8022 A Do Not Write BeIc4 This Line <br /> EPA 8700-22 <br /> ' (Rev.6.89)Previous editions are obsolete. <br /> - GREEN: HAULER RETAINS <br />