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State of California-Health and Welfare Agency Department of Health Services <br /> Form Approved OMB No.205D-0039(ExpiresU=-88) Toxic Substances Control Division <br /> �.nIs as rint or type. Form desi ned for use a 12 itch typewriter). Sacramento,California <br /> UNIFORM HAZARDOU 1. Generator's US EPA ID No. Do Man. M 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST q, 7 1 of is not required by Federal law. <br /> 3. enerator' N a end ailing Address A. State Manliest Document Number <br /> I l't ' d Tail i,M P°' 61y'` )q3 B. State Generator's87955659 <br /> ��(�/ 4TA), (r QS 3�1 <br /> 4. Generator's Phone r�0 ).576 woo C 0 l <br /> O 5. Tr sp er 1 om any Name 8./'' /USS EPA <br /> j ISD Number Q State Trensporter's ID2,31 <br /> L ,0 -L O V 7 S D. Trenaporter's Phone <br /> r <br /> m77. ,Tra'nspo1r(Iat 2 Company NTme _ 8. US EPA ID Number/ E. State Transporter'e <br /> p yv-'L7�u�l` Z7(/)esCAPP v /( F. Transporter's Phon <br /> J F/esi pled acility qld6101 1132 5-2 1- <br /> ��erytlGi�Adtlrass G ,rf� PA ID Number G. State Facility's ID <br /> ` < 1`J GLQO �rJI QpO H. Fact'ty a,P one <br /> z <br /> CoM �n G� �G�a� f osG v ( 3s 531- 7 �cri <br /> X 12. Containers 13. T tel r14.O11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Waste No. <br /> No. Type t h b� L State <br /> U a� O( �-!JMG5�! [ LI ' EPA/Ocher <br /> E IvA l U <br /> _r N <br /> 3 E b. State <br /> N R <br /> mA EPA/Other <br /> v T <br /> N O State <br /> v R c. <br /> 0 <br /> r <br /> m EPA/Other <br /> W d State <br /> r <br /> Z <br /> w EPA/Other <br /> U <br /> W <br /> Z J. Additional Descriptions for Materials Listed Above a. Handling Codes for Wesbtes Listed Above <br /> O <br /> y <br /> w <br /> a d. <br /> O ,.., ,. ....,_.... <br /> G 15. Special Handling Instructions and Additional Information <br /> Z <br /> 2 <br /> F <br /> J <br /> Q <br /> U fi. <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 /> a <br /> y If I am a large quantity generator, 1 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 <br /> O 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. <br /> 2Month Day Year <br /> W Prince p d <br /> No <br /> Signature <br /> W <br /> w it <br /> wT 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R Month Dey YeaQr <br /> Z A Printed/T ed Te / / Signature y <br /> LL S n <br /> O P 18. Tra p iter 2 Acknowledge ent of Receipt of Materials <br /> w 0 Month Day Year <br /> m R Printed/Typed Name Signature <br /> Q T <br /> U E <br /> Z <br /> - 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <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 /> g Month Day Year <br /> � Printed/Typed Name Si nature <br /> DHS 8022 A 0/87) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS INSTRUCTIONS ON THE BACK <br /> EPA 8700-22 <br /> (Rev.9-88) Previous editions are obsolete. To: P.O. Box 3000, Sacramento, CA 95812 <br />