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State of California—Health and Welfare Agency See Instructions on Back of Page 6 Department of Health Setvicu <br /> Form Approved OMB No.2050--0039(Expires 930 and Front O} a Toxic Substances Control Divi& <br /> Please print or type. Form designed for use on elle .-pitch typewriter). Sacramento.Celiforr� <br /> UNIFORM HAZARDOUS Generanr'e us EPA lD Ne. Manueah 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST A (� of s net required by Federal law. <br /> 3. Generator's Name and M ilio,Addr se A. State Manifest Document Number <br /> ct>ti4�r �n QQ Jr`c�Q � � y,� /T 9 0 3 8 2 7 4 6 <br /> y3D 6 z LAW'19 a-•— wA% �t �r^'(ETON (,A 9. State Generator's IO <br /> 4. Generator's Phone( qu& .'Z 3 J111111111111 <br /> n 5 Transporter 1 Company Name 6 US EPA ID Number C. State Tranaporter'a ID _ <br /> / - C O 3 D. Transporter's Phone / L. <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter',ID <br /> m _ <br /> Oo F. Transporter's Phone <br /> c^0 9. Designated Facility Name and Site Address 10 US EPA ID Number G. State Facility's ID <br /> Ra H. Facility's Phone <br /> Q/ a it 7/ . ZS-7® <br /> �¢ r 12 f.mainers 13. Total 14. I. <br /> 0 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit West*No. <br /> J No, Type WUVol <br /> j 00 z /V O M 9 C g/¢ 64z•4� 0ous: Bt:`g�1! LL <br /> M2 G n 7 EPAA10ther <br /> C); N l V� r _ <br /> E b. State <br /> iv R <br /> A <br /> T EPA/,her <br /> N Q <br /> R a State <br /> EPA/Other <br /> ¢ d state <br /> w <br /> Z <br /> Z <br /> U.1 EPA/Ocher <br /> ' U <br /> W J. Add''oral Descriptions for Materials Listed Above K. liandlatp Codes for Wastes Listed Above <br /> R �/,4� Ri lis `J � P/ /���c�wi b. <br /> C S M M(7—Q— / i/*v<L C. d. <br /> J <br /> Q <br /> 0 <br /> F <br /> 15. Spacial Hendl' g instruct ns end Additional Information - <br /> W (/�� %VP%Io��rm� �/1�1T7!/� -x/77-7�� . <br /> J <br /> L) 8. <br /> GENERATOR'S CERTIFICATION: I hereby declare that 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 <br /> ¢ If I em a large quantity generator,I certify have I have a program in place to reduce the volume and toxicity of os ate generated <br /> available <br /> to the degree have determined <br /> O pr be economically practicable and that have selected the practicable m a s 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 em a smell quantity generator.I neve made a good faith effort to minimize my waste <br /> Ugeneration and select the beat waste management method that is available to me and that I can afford. <br /> uePrinted/Typed Name Si re 11 // Month Day Year <br /> low,Z*11 <br /> wW T 1 —reneporter i Acknowledgement <br /> R of Receipt of M <br /> Z <br /> Y <br /> < A Printed/Typed Name Sipnah a Month Day Year <br /> N 1 Q <br /> 0 S / C <br /> U P <br /> w O 19. Transporter 2 Acknowledgement of Receipt of Materiels <br /> Q T Printed/Typed Name nature Monte Day Year <br /> U E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> I <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 Yeer <br /> I <br /> DHS 8022 A Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.6-89)Previous editions are obsolete. White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAY, <br /> To: P.O. Box 3000, Socromento, CA 95812 <br />