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UNIFORM HAZARDOUS •"' u E ' f q <br />WASTE MANIFEST ' <br />3. Generator'} ,Nems and Mailing Addnslew/ <br />/✓u.aL VGG!'ilpruAL. /N='�' CRD <br />��/qc jf i<Ct�.so IJ Hr�( <br />4. Gafor s Phone ('i ) ! > �y ! LI I <br />erter <br />lifivt 2. rage 1 Information In tM shaded areas <br />ow=.". of I is not required by Federal law. <br />Y <br />Q��77Transporter 1 Company Name / a. US EPA ID Number C. State TrartWarleh ID <br />(JCL, A -L l •r v it - 14 I.+ r.. S a e/, i t- 1 I I I I I D. Traaponer's Piton. , f - — / � I <br />7. Transporter 2 Company Name a. US EPA ID Number I E. State Trasspor1w • 10 <br />t F. Transports/a Phone <br />Q. Designated Facilely Name, and Site Address 10. US EPA ID Number G. Slate facility's ID <br />J ,csSOhr *,L S /�Cl�i'N/Ny l.0 INC <br />U `irVCd OF rois'a lir A -I De KFacuiry's Phots <br />j 7? �v•� -C� /� a' 3�� -qA1 fr, Y 93 11-717 gD,B>7—o41/3 <br />I R12. Containers 13. Total 14. <br />OLL 11. US DOT Description (Including Proper Shipping Name. Hazard Class, and ID Number) Quantity Unit <br />Ib. Type Wt/vc <br />Q a. <br />K G llw7f7 C1O'S ifJrc�: L.'G'II Y 1, / L%F/irF /vN GI�3`1 <br />E <br />f 3 N <br />E b. <br />N A <br />w A <br />I T <br />N <br />R C. <br />A <br />N <br />S <br />P <br />O <br />R <br />Waste No. <br />2% <br />State <br />tYA/tJtMl <br />'J. AdyN10N1 Descriptions lor Materials Luted Above e."` �J [ tYnoting Codes for Wsales LTated Above <br />C 9 D. <br />�.._ r.. <br />fav`�o-caa�R EB.1 1989 <br />15. Special Handling Instructions and Additional Atformation ENVIRONMENTAL HEALTH <br />PERMIT / SERVICES <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br />name and are classified packed, marked and labeled, and are in all respects in proper condition for transport by 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 to the degree I have <br />determined to be economically practicable !M that I have selected the pradigaba method of treatment, storage, or disposal currently available to <br />me which minimizes the present and future t last to human health and the environment: OR, if 1 am a smell quantity generator, I have made a goad <br />faith effort to minimize my waste generation and select the bast waste management method that is available to me and that I can afford. <br />rated/Typed Name Signstaai Month Day Year <br />. Transporter I Acknowledgement of Receipt of Materials <br />nted/Typed Name - Signature Month DIY Year <br />. Transporter 2 Acknowledgement of Receipt of Materials <br />tiled/Typed Name Sigrutaa Month Day Year <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />L20. Facility Owner or Operator GrtBicat on of receipt of hazardous materials poverea by :his mamfeat except as noted in uem 19. <br />T Printed/Typed Name Sipatore <br />V <br />DHS 8022 A (1/87) Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />EPA 8700-22 <br />(Rev. 9.8111 Previous editions are obsolete. To: P.O. Box 4001 Sacramento, CA 95802 <br />INSTRUCTIONS ON THE BACK <br />