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State of Callfomia-Health and Welfare Agency Department of Health Services d <br /> Form Approvep OMB No.2050-0039(Expires 9-30.88) Toxic Substances Control Division <br /> Pill se print or type. Form designed/or use on elite(12-bitch itch t ewrifer. Sacramento,California <br /> UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST Document No. of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address n A. State Manifest Document Number <br /> Ailfi;V1A4 tet).,, Yu6c lc13 � C <br /> `, -7C <br /> B. State Generator's lD <br /> 4. Generator's Phone brL ' <br /> 4 ) 7C-k I ( F 7 <br /> 5. Transports r 1 Comprify Name 8. US EPA ID Number State Transpo er's ID ? <br /> Transporter'.!hon <br /> 7. Transporter 2 Company Name 8. S PA ID Number E. State Transporter'e I - <br /> / l F. Transporter'.Ph., <br /> 9. DD�e�ssig�n}at}ed Facility Name and Site Address -2 <br /> /I � y10. US EPA IDD um er G. State Facility's ID V. <br /> /Jl /r/f' 1/t(✓ /'�j/ /1 Tr-'IJU�-F /(.Inf lr'r '[., F iii Y' It I <br /> p <br /> CA- CA <br /> 12. Contain r 3. Tatill- 14. <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. 1 <br /> I_ / 1 / No. Type Wt/Vo <br /> G a state <br /> WC/� C,r J //J � Ill rC. Lrpp (,�i/IN AILS AIA 12-70 1 11 Qioai <br /> d <br /> Eb. ( J <br /> R state <br /> A <br /> T EPA/Other <br /> O <br /> R C. <br /> State I <br /> EPA/Other <br /> d. <br /> State <br /> EPA/Other <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wsales Llsteq.Above <br /> a. b. + <br /> C. d. <br /> ffI <br /> 15. Special Handling Instructions and Additional ImormYtion <br /> 1 <br /> I I <br /> ( <br /> 18. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurate) described above b t <br /> 9 Y y proper snipping <br /> name and are d national packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> international end national government regulations. <br /> If 1 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 and that I have selected the practicable method of treatment, storage, or disposal currently available to 1 <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 I can afford. j <br /> i <br /> Printed/T ped Name / Signature Month Day Year <br /> / " <br /> R17. Transporter 1 Acknoledgembnt of Receipt of Materials - 1 <br /> A PimtediTyped Name Si nature <br /> R 9 Month Day Year <br /> P /En <br /> O 18. Transporter Acknowiedgemaht of Receipt of Materials <br /> RT Printed/Typed Name Signature - 1l <br /> E Vel <br /> I 3IS <br /> 19.f Eiriscle ency dication 690 t <br /> F i <br /> C MAY 191989 , <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. ENVIRONMENT 1 F <br /> V -Printed/Typed Name Signature �E. „ Year <br /> IS 8702 A(i/67) <br /> r A 8700-22 Previous editions are obsolete. INSTRUCTIONS ON THE BACK <br /> 'ev.9-88) PYELLOW: GENERATOR RETAINS <br /> I <br /> s <br /> 1 <br />