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Stale of Califomia-Health and Welfare Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-e' <br />Plnnnu e.t <br />Department of Health Service: <br />Toxic Substances Control Division <br />9eeremenM Calif.:. <br />DHS 8022 A (1 /87) Blue: GENERATOR SENDS THIS COPY TO DOH5 WITHIN 3U UATJ INS I nuc I luno vn I ne D.,,, <br />EPA 8700-22 <br />(Rev. 9-86) Previous editions are obsolete. To: P.O. Box 400, Sacramento, CA 95802 <br />UNIFORM HAZARDOUS t. Generator's US EPA ID No. Manifest <br />ocum of No <br />2. Page t <br />Information in the shaded areas <br />WASTE MANIFEST <br />of I is not required by Federal law. <br />3. Generator's Name and Mailing Address .f <br />A. State Manifest Document Number <br />SUITrY /1`851218 <br />Fy 1, <br />7 <br />(;G bJ. rj I.HIII Kai 11� <br />ll,lUa <br />i <br />Is C, �) ,// e; Ayr <br />���i.-/'(��_7r 01 ' <br />B. State Generator's ID <br />4.Ge a re aIVK, <br />i TJ <br />S. Transporter 1 Company Name 8. US EPA ID Number <br />C. State Transporter'a ID <br />D. Transporter's Ph y <br />_ <br />i_l , _11,4— <br />7. Transporter 2 Company Name e. US EPA ID Number <br />E. State Transporter's ID <br />F. Transporter's Phone <br />9. Design 1 tl FgCil[ty, F aad.Sit' A�tltlIZIE 10. US EPA ID Number <br />e <br />� YLJNG` <br />G. State Facility's ID <br />2�o GH I N,11% (Z IL N <br />H. Facility's Phone 3 <br />9 11 D _ <br />x�(i' S — Q 906 <br />12. Containers <br />13. Total <br />14. <br />I. <br />11. US DOT Description (including Proper Shipping Name. Hazard Class, and ID Number) <br />Quantity <br />Una <br />Waste No. <br />- <br />No. <br />Type <br />Wt/vo <br />.��rrE m PTY++ ©1 L TANK l vA s'rE <br />Bt.: Z <br />lo <br />�% <br />f:PA/ Aar <br />E <br />N <br />COM8V51 I ULE: L.I Q(J) n NA I Z% O <br />E <br />b. <br />State <br />R <br />EPA/Other <br />A <br />T <br />OR <br />c <br />State <br />EPA/Other <br />d <br />State <br />EPA/0ther <br />J. Additional Descriptions for Materials Listed Above <br />-N '% A &E:T� <br />K. Handling Codes for Wastes <br />a. <br />Listed Above <br />b. <br />E m V V K D e r� K00 N p <br />w ITK t E5 1—fTiAN 1% i�S1D1%AL' L►�ijvl D <br />c. <br />It. <br />16. Special Handling Instructions and Additional Information <br />le. <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents this consignment are fully and accurately described above proper shipping <br />name and are classified, pecked, marked, and labeled, and are in ellll respects in proper condition for transportby highway according to applicable <br />international and national government regulations. <br />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 t0 the degree I have <br />I have the method of treatment, storage, or disposal currently available to <br />determined to be economically practicable and that selected practicable <br />me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator, I have made a good <br />faith effort to minimize my waste generation and select the best waste management method that is available to me and that 1 can afford. <br />Printed/Typed Name <br />Signature-�'- \ Month Day Year <br />4✓ 4 <br />_y+— p <br />I L_I.. I li IV J tJ /9 _L S <br />�GG-G 4«.� c �\ i �_ •l� J7 U <br />17. Transporter 1 Acknowledgement of Receipt of Materials '" <br />RMonth <br />A <br />Printed/Typed Name <br />Signature Day Year <br />N <br />B <br />IVA <br />P16. <br />O <br />Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed /Typed Name <br />Signature Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in sem 19. <br />TSignature <br />Printetl/Typed Name <br />Month Day Year <br />Y <br />DHS 8022 A (1 /87) Blue: GENERATOR SENDS THIS COPY TO DOH5 WITHIN 3U UATJ INS I nuc I luno vn I ne D.,,, <br />EPA 8700-22 <br />(Rev. 9-86) Previous editions are obsolete. To: P.O. Box 400, Sacramento, CA 95802 <br />