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-_�_ _ _ _ _ _ _ _ _ _ _ <br /> / t altlornia---Health and Welfare Agency Department of Health Services <br /> ,roved OMB No.2050-0039(Expire.9.30-. Toxic Substances Control Division <br /> Tint Of type. (Form desi ned for use on elite 12-pitch typewriter). . Sacramento.Caultimin <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Pepe 1 InTormetion in the shaded areas <br /> WASTE MANIFEST � C" Document N0. of is not required by Federal law. <br /> 3. ane� ator's am nhatMel ng Atldress A. State Manifest Document Number llie� �cftireti�n /q3 ., <br /> ' I,. � /�YII/qU/r <br /> CA B. State&12 ID <br /> a. Generator's Phone 1-T-A,/) 7 _(SS (�53 /" N 0 S! a <br /> n5.AT ansporte 1 C pany me 8. US EPA ID Number C. Stale Tranaportar'. <br /> D. Tranaporter'e Ph _ <br /> '0 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter'• D <br /> m 1 <br /> o ✓i qj k. F. Transporter'.Phom a! <br /> �9 esignated Facility Nam�fand Sia Address 10, US EPA,II Number G. Slate Facility's ID <br /> e /y1e�nG l(�r ipn ao� �Ct,:47 U 3 s <br /> U H. Flittle Phone <br /> z Cep, �vli Ca q0 )-,2-q- C�C1 3.3 S' 75l 7 0 <br /> ¢ 12. Containers 13. Total 14. I. <br /> t 1. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Will No. <br /> G No. Type Wt/Vo Slate <br /> K G a.Wus e oil <br /> = E I IC EPA/Other <br /> N ) <br /> 3 Eb. <br /> oR State <br /> m A <br /> m T EPA/Other <br /> e <br /> o R <br /> C. ., Stu• <br /> 0 <br /> m <br /> EPA/Other <br /> w d. State <br /> Z <br /> Z <br /> w <br /> U <br /> EPA/Other <br /> w <br /> Z J.,(`d florist Descriptions for Material.Listed Above K. Handling Codas for Wastes Listed Above <br /> /I k/a <br /> w <br /> C. it. <br /> J <br /> Q y <br /> Z <br /> O <br /> 4 16. Special Handling Instructions and Additional Information _ <br /> x , <br /> J <br /> Q 18. <br /> U GENERATOR'S CERTIFICATION: I herebydeclare that the contents of this consignment are lull and accurately described above h <br /> y y proper shipping <br /> name and are classified, pecked, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> h <br /> international and national <br /> government regulations. <br /> m 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 and that I have selected the practicable method of treatment, storage, or disposal Currently available to <br /> 0 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 beat waste management method that is available to me and that I can afford. <br /> U <br /> Z <br /> Prinletl/ yped Name Stgilure Month Day Year <br /> W <br /> gFj R 17. Transporter 1 Acknowledgem nt of Receipt of Materials <br /> A Print /T pedNeme r Signature <br /> N Month Day Year <br /> u.O P (✓ <br /> W O 18. enep -Ilarnent of Receipt of Materials <br /> < R Printed/Typed Name Signature Month Day Year <br /> U E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materiels covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name <br /> y Signature Monts Day Year <br /> DHS 8022 A(1/87) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS INSTRUCTIONS ON THE BACK <br /> EPA 8700-22 <br /> (Rev.9-86) Previous editions are obsolete. To: P.O. Sox 3000, Sacramento, CA 95812 <br />