Laserfiche WebLink
l 4 <br /> State of Californla-44ealth and Welfare Agency ``r y F,ex. Department of Health Services <br /> Form Approved OMR No.2050--0039(Expires 9.3LNa� R•fuCt, n Toxic Substances Control Division <br /> I Please print or type. (Form designed for use on elite(12-pitch typewrite'). [ r .] Sacramento.California <br /> a UN¢ORM HAZARDOUS f jg <br /> Vy Gene eco a US EPA ID No. Manifest, 2 P a t <br /> L 7 {j ^ 'r) ( Ll Document No. Information a the shaded areae <br /> WASTE MANIFEST. - t" � of is not required by Federal law. <br /> 3. Generator's Name and Mailing AddressA. State Manifest Document Number <br /> 3i ii NF;T WJAI) F:;, <br /> it } t t r". R. Stale snare oPa <br /> 4. <br /> "orator s `ne�( ) s ,�1 _ - i ` i( v i <br /> 0 S. Transporter 1 Company Name 8. US EPA 10 Number C. State Tranaparter's ID <br /> N . . <br /> ' � ' � " D. Transporter's Phone <br /> ze..e <br /> n <br /> O T. Transporter 2 Company Name B. US EPA ID Number E State Transporter's 10 <br /> 8 F. Transporter's Phone <br /> m <br /> 1 9 DeAigneted Faclldy f{amB eM Site Address 10. 115 EPA ID Number G. State Facility's ID - <br /> tiJ� IIIIIIIII <br /> a H. FecIilitYI'a Phone <br /> < <br /> � 2 <br /> U 12 Containers 13. Total II. <br /> W 11 US DOT Description(Including Proper Shipping Name,Hazard Claes.and ID Number) Quantity Unit Weele No. <br /> N < " No. Type WtIvol <br /> e <br /> Siete <br /> �y� U <br /> W <br /> 9 E <br /> EPA/Other <br /> N nap <br /> n a ° CO-/)7//UC-/E D f 2 / e L m7 stale <br /> c <br /> s T /G YI�uC �i2c7r7 � )k # 39 /y <br /> < O / / yV) /t�5-_,/ } EPA/Other <br /> o Ra - ,_' State <br /> 8 <br /> m <br /> _ EPA/Other <br /> ¢ — <br /> 1- tl Siete <br /> 1- <br /> Z Z <br /> (W) EPA/Otho, <br /> W <br /> W J. Additional Descriptions For Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z ;lig 2 6:'v'i. -Y`•. - '. 4Y _ . . a. to <br /> WQ i[en t 4... 1 .Fl < ):i • YI( i 1 -I . ...ii ,. <br /> `c. <br /> it <br /> J <br /> <_ <br /> O <br /> H 18. Special Handling Instructions and Additional Inlormation <br /> J <br /> J <br /> O 18. <br /> -j GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J <br /> and are classified,packed.marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable International and <br /> Wnational government regulations. <br /> M If 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 /> O to be economically practicable and that 1 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 1 am a small quantity generator.I have made a good faith effort to minimize my waste <br /> U generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> W Printed/Typed Name _ Sipneture Month DeX Year <br /> 5 _ y <br /> ¢ j ' <br /> W _ AV 77 <br /> wT t7. porter t Acknowledgement of Receipt of Materials <br /> R <br /> < A Prince Oear <br /> U P <br /> W O 18. TrTnsponer 2 Acknowledgement 1 Receipt of Materials <br /> N <br /> ¢ R Printed/Typed Name Signature Month Day Year <br /> U E <br /> Z_ <br /> 19, Discrepancy Indication Space -"- - - <br /> F <br /> A <br /> C <br /> I <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T <br /> y Printed/Typed Name Signature Month Day Year <br /> EIRE-0 El. i.. ?�iHr') L=:.)TL rr' s, _.rt ":c'r:,'.,' i r'>s—.': <br /> DHS 8022 A(I/Be) Do Not Write Below This Line YELLOW: GENERATOR RETAINS <br /> EPA 8700-22 <br /> (Ray.9-88)Prevloue editions are obcoletq- <br />