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State or California—Health and Welfare Agency See Instructions on Back of Page 6 Department of Health Service <br /> Fgrm Approved OMB No.2050-0039(Expires 9-30-911and Front of Pp-,i 7 Toxic Substances Control Divisic.Please print or type. Form tleai0netl for use on elite itch typewriter). Sacramento.Callfornu <br /> UNIFORM HAZARDOUS enarator'e US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST Document Np. of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State M innest Document Number <br /> CIMRTA� AVAO /DiSMA�t�Lri S 20382746 . <br /> 9.30 e, C r4F K +� snX a rcIj, eal B. State GeneratoYe ID <br /> 4. Gan rator's Phone( _ 04 <br /> _ ("N /�.� <br /> N 5. Transporter 1 Company Name US EPA M umber Ols' C. State Transportar's iD <br /> ^ <br /> D. Transporter's Phone <br /> '7r C <br /> n ranaporter Comps y ems B. S PA ID a <br /> Other E. State Traneporler'a ID <br /> m <br /> d F. Tranaponer'e Phone <br /> 0 <br /> °D 9. Designated Facility Name and Site Address 10. US EPA ID Number O. stale Fadliry'a IO <br /> fii?Ava FAl(J/l�CH,/J�1nIJ7I/L- SL(�iC. t{ /�C.4/, <br /> /,S / S SoI/Thf /� ! �J• H. <br /> tog d9t e nst <br /> 12. Con 'a 13. Total 14. I. <br /> �O 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> �aeLL Alz� / d /- {,J' /, No. Type Wt/VolState <br /> 04( <br /> 00Z E a Al O A 1 �!r ��fFJ T/�VVW EPA/Offmar t <br /> _r <br /> N do.,Ii loaL AZ hol IS <br /> E b. - <br /> w'� A EPA/OSTM <br /> T <br /> n' R C. State <br /> a <br /> 8 EPA/Other <br /> OP <br /> ¢ d Stan <br /> W <br /> 1– <br /> Z <br /> tp EPA/Other <br /> U <br /> h J. Addhignal Descriptions forMaterials Listed Above K. HendlNg Cotlee fM Waatee Listed Above <br /> w PC <br /> C'j��yt fJI�l� c d <br /> J <br /> Z <br /> Z <br /> O 15. Special Handling Instructions and Additional Information <br /> p cw li iw" CfA.-�>Pce <br /> Z (/ l�f�o��i/h �Jilll7 ivy- C /hL 7 72 <br /> JJALr& f <br /> J <br /> U 3. <br /> GENERATOR'S CERTIFICATION: I hereby declare th the contents of this consignment are fully and accurately described above by proper shipping name <br /> J 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 /> a national government regulations. <br /> W I cerci that I have a program in lace to reduce the volume and toxicity of waste generated to the degree I have determined <br /> (T <br /> If l am a large quantity generator, codify p g P <br /> O to be economically practicable and that I 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 I am a small quantity generator.I have made a good faith effort to minimize my wsets <br /> > g <br /> U 1 eneration and select the beat waste management method that is available to me and that I can afford. <br /> Z _ Month Day Year <br /> W Printed/Typed Name Signature <br /> IT <br /> w <br /> w T 1 rens o a 1.AclialowleMbirribrif of Receipt of Materials ar % <br /> RSignal re Month Day Yeer <br /> A Printed/Typed Name <br /> N 2 <br /> O p <br /> W O ' ap a Ackn iedgement a ep atonal _. <br /> U R Printed/Typed Name store <br /> Month <br /> 1 Day Yen <br /> E <br /> Z <br /> 19. Discrepancy lntlloatbn Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materiels covered by this manifest except as noted in Item 19. <br /> T Printed/Typatl Na Signature Month Day Yeer <br /> _OL <br /> Dns 8022 A Do Not WjtCBIow Thi tine <br /> EPA 5700-22 <br /> (Rev.6.89)Previous editions are obsolete. <br /> 10 C•eNEkATCk WITHIN 30 L- <br />