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Slate of California-4ieahh and Welfare Agency Department of Health Services <br /> Form Approved OMB No.2050-0039(Expires 9-30-88) `� Toxic Substances Control Californiav1 <br /> pD D `/ Sacramento, aomia <br /> Is as mint or true, Farm designed for use on elite(12-Pit t ewhilm. <br /> UNIFORM HAZARDOUS II Generator's US EPA ID No. no <br /> anifest <br /> 2 Pegs I information in the shaded areae <br /> WASTE MANIFEST p' snot required by Federal law. <br /> 3. Generator's Wm and Mail"Address <br /> - <br /> ' A. Stale Manifest Document Number <br /> s ,q <br /> A/16/ /�e�ro�c�Hl 10cl,6vt- ifi <br /> Y'h , B. State Gs r or <br /> f�nlr/r <br /> a. Generator's Phone( -1, - <br /> 1 5. Transporter 1 Company Name 8. US EPA ID Number S ate r ns orler's <br /> to <br /> i 1 _ f D. Tnneportar'a Phone <br /> i 7. r l po 2 Comb n Name •' US EP 1 N er 4444 <br /> E. Blare Treneportar's j,),n - <br /> It I <br /> 7 �. _ F. Trensporte,8 Ph <br /> 7 <br /> 0 <br /> 9. ei0na ed Facially Name end Site rase a. USE R ID urd er O. Slate FaefINY's ID <br /> . FecllitY.a M <br /> 7 7 <br /> [ TI <br /> r Containers 13. of I a. Wash t <br /> No. <br /> T 11. US DOT Description(Including Proper Shipping Name,Hazard Class.and ID Number) Quantity Unit <br /> No. Type NOVO <br /> i // //-- // w / stale <br /> G <br /> ( a �4 cid W h T hl LE <br /> � E 1 <br /> N Stela <br /> E b. <br /> vR EPA/dMr <br /> °u A <br /> N O c Stals <br /> 3 R <br /> EPA/Other <br /> a <br /> stale <br /> y d. <br /> 2 EPA/01her <br /> W <br /> U <br /> w K. HantlHng Cortes for Westss Llsted Above <br /> 3- Addimenal Descriptions for Materiels Listed Above b- <br /> Z a. <br /> a <br /> w I e. d• <br /> J � <br /> Q ' <br /> Z <br /> 0 15. Special Handling Instructions and Additional Information <br /> Z <br /> w <br /> I <br /> � r <br /> J <br /> J <br /> U 8. <br /> name and are CERTIFICATION: I hereby declare that the are i to of this consignment are lolly and accurately described above rd proper sipping <br /> applicable 1 name and are classified, packed. marked, and labeled, and are In all respects in proper condition for transport by highway according to applicable <br /> j international and national government regulations. <br /> N <br /> If I em a serge quantity generator.I certify That I have a program in place to reduce the volume and tonicity of waste generated to the degree I have <br /> determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to <br /> 0 me which minimizes the present and future threat to human health and the environment;OR, it 1 am a small quantity generator, I have made a good <br /> > faith effort to minimize my waste generation and select the beat waste management method that is available to me and that l can afford. <br /> USignature Month DaY Yaar <br /> Prinlad/Ty ed Name ;1 <br /> M - <br /> F17. Tr e 1 Acknowledge nt of Receipt of Materials <br /> w Month Do; Year <br /> Z A Primed/Typed Name Signature <br /> N - <br /> O P 18. Tra er 2 Acknowledgam nt of Receipt of Materials <br /> O Month Day year <br /> T Prinlad/Typed Name Signature <br /> U E <br /> Z <br /> 1 Discraa noy Indkelion Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except ea noted in Nem i . <br /> T Signature Month Day Year <br /> Y Prinlsd/Typed Name <br /> DHS 8022 A(1/87) Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS INSTRUCTIONS ON THE BACK <br /> EPA 8700-22 To: P.O. Box 400, Sacramento, CA 95802 <br /> (Rev.9-8e) Previous editions are obsolete. <br />