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State of orma—Health and Wellere Agency <br /> Farm Ap ad OMB No.2050-0039(Expires 9.30-91) (� See Instructions on Back of Pa�6 Department of Health Services <br /> Ple►'e) oi type. (Form OesiDned <br /> for <br /> use do elite(12-p pewnfer). and Front Of Pa a Toxic Subatancee Control Division <br /> UNIFORM HAZARDOUS a saeramento,California <br /> 1. Generator's US EPA ID No. Manifest 2. Page 1 <br /> WASTE MANIFEST 1 o m t o/ 1 nformation in the shaded areas <br /> O of / is not required by Federal law. <br /> 3. Generator's Neme and Meiling Atldress <br /> f7.6. ; t_ A. State Manifest Document Number <br /> /O '�•[•.:/V�Y /L o 9 s'77/ B. State Generator's I <br /> 4. Generator's Phone ) _ <br /> N 5. Tra apaner 1 Company Name <br /> n JJ 6. US EPA ID Number C. State Trensporter's ID - <br /> r G�' i7 I!/(✓ Transponer's Pho <br /> mm 7. Transporter 2 Company Name 8. Us EPA ID Number <br /> 0o E. State Transport <br /> m F. Transporter'e Ph ne <br /> 9.Deesiggated Facility Name and Site Atldress 10. US EPA ID Number G. State Facility's ID <br /> m U <br /> a 5�6 i✓�/Jcd <br /> _ _ < H. Facility's Phone <br /> ¢ lc�ir»owal. L'� O �cS EA9H <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total <br /> J <br /> �U a. 5 _�,/ �J No. Type Quantity unit Wt/Vol Waste No. <br /> >o Z tv.9 >� /'�y sT�✓f/q �/ State s� <br /> G p3 E � 6a90,1,0q—Z1 <br /> � I I EPA/Other <br /> C 2D�r/ <br /> mA State <br /> CP T <br /> tP.l O EPA/Olhar <br /> v R C. <br /> o State <br /> m <br /> EPA/Other <br /> W d. <br /> 1- <br /> Z <br /> St <br /> W ets <br /> U <br /> N tst =- <br /> 0- <br /> ZJ. Additiaerasisted Above �/ 'O K. Handling Codas for Westea Above <br /> int y/ ���dP� y�9sd/iy�„x $ a I b. <br /> �d rd,rb( ;l �,GJ� dory v <br /> d. <br /> C.Z <br /> O <br /> ti 15. Special Hentlling Instructions and Additional Information <br /> Z <br /> 2 <br /> F- <br /> J <br /> Q 16. <br /> U <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> Jend are classified,packed,marked,and labeled,and are in 811 respects in proper condition for transport by highway according to applicable international and <br /> OL national government regulations. <br /> 0 <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 1 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 /> y present eno future intent to human health and the environment,OR,if 1 am a small quantity 9enerater,i have made a good faith effort to minimize my waste <br /> Z <br /> U generation and select the best waste management method that is available to me and that I can afford. <br /> W Printed/Typed Name <br /> O Signet <br /> w Month ay. Year <br /> a <br /> W T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> G A Printed y d Name <br /> O 3 ,t�� Sig re ) Month Day Year <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materials / <br /> N <br /> U R Printetl/Typed Name Signature <br /> Z E g Month Day Year <br /> 19. Discrepancy Indication Spec, <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materiels covered b <br /> T y nifest except as ted in 19. <br /> y Printed/Typed Name <br /> Signature <br /> Month ++Day Year <br /> DHS 8022 A(1/88) 1 8 <br /> EPA 8700-22 Do Not Write Be ow This Line White: TS S THIS COPY TO DOHS WITHIN 30 D, YS <br /> (Rev.9-88)Previous editions are obsolete. <br /> o: P.O. Box 3000, Sacramento, CA 95812 <br />