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Please Print Or avewJV Expires9-30.88) t <br /> p type. (Form designed for use on elite r'- In$YrUCYi Department of Health Services <br /> UNIFORM 7Itch typewriter). DA$ OA the Rack Toxic Substances Control Division <br /> HAZARDOUS unerator's US EPA ID No. Sacramento,California <br /> WASTE MANIFEST \ Document <br /> 2. Page 1 <br /> Document No. Informations the shaded areae <br /> 3. Generator's Name and Meiling Address of is not required by Federal few. <br /> e State Manifest Document Number <br /> 4. Generator',Phone( ) B. State Generator's ID <br /> qOi 5. Transporter f Dampen y Name <br /> 8. US EPA ID Number C. State Transporter's ID <br /> b <br /> m 7. Transporter 2 Company Name D. Transporter's Phone <br /> 0 8. US EPA ID Number E. State Transporter',ID r v r <br /> m <br /> 9. Designated Facility Name and Site AddressF. Transporter's Phone - <br /> J Urinary 10. US EPA ID Number G. State Facility's ID <br /> ry Services <br /> ria " 13331 !1e Fighwaq 33 <br /> V <br /> Z ftttAWSM CA ss3$,Y H. Facility's Phone <br />•-10 A 0 0 $ 3 1 6 6 7 2 R ROO-974-4444 <br /> M LL 11. US DOT Description(including Proper Shipping Name,Hazard Claes,and ID Number) 12. Container, 13. Total 14, <br />�1 J <br /> No. Type Quantity WUnit waste No. <br /> 00 3 E Calitoraia nagnlate"Iftete Only State <br /> OD N EPA/ er <br /> MW/ E b. <br /> R <br /> A State <br /> T <br /> NO EP,i-nnar <br /> e R c. <br /> 9hte <br /> EPA/Other <br /> W d. <br /> ti <br /> Z State <br /> w <br /> U <br /> EPA/Other <br /> w <br /> m J. Additional Descriptions for Materiels Listed Above <br /> Z Handling Codes for Wastes Listed Above <br /> O a,e. b <br /> LU 01—R <br /> C. it <br /> J <br /> Z <br /> Z <br /> O <br /> H 15. Special Handling Instructions and Additional Information <br /> Z <br /> U.1 hear gloves <br /> J <br /> J <br /> U B. <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 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 /> 0. national government regulations. <br /> m <br /> R If 1 em a large quantity generator.I certity 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 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 waste <br /> U generation and select the beat waste management method that is available to me and that I can afford. <br /> Z Printed/Typed Name Signature Month Day Year <br /> (7 <br /> W <br /> WT 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> Q A Printed/Typed Name Signature Month Day Year <br /> N <br /> W O 18. Transporter 2 Acknowledgement of Rece' td/Materials <br /> U R Printed/Typed Name Signature Month Day Year <br /> E <br /> 2 <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materiels covered by this manifest except as noted in Item 19. <br /> T Signature <br /> Month Day Year <br /> y Printed/Typed Name 9 <br /> DMS 8022 A(1/88) Do Not Write Below This Line YELLOW: GENERATOR RETAINS <br /> EPA 8700-22 <br /> (Rev.9.88)Previous editions are obsolete. <br />