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State of California-Health and Welfare Agency <br /> Form Approved OMB No.205G-0039(Expires 9. Department of Health Servic.Toxic Substances Control <br /> Please rinl or 1 e. Form designed for use on - itch f ewrifDivisi.er. Sacramento,Califon <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Page 1 <br /> Document No. Information In the shaded areas <br /> WASTE MANIFEST of a not required by Federal law. <br /> etor' No end Melll Atltlresa A. State Manifest Document Number <br /> 87955533 <br /> rN 4. Generator's <br /> enerator's P <br /> hone(/) S76 E <br /> S. State Generator's ID <br /> 0 rf C <br /> J <br /> S / <br /> N yNa a US EPA ID Number C. Stole Traneponer'e ID� )3 <br /> _ aae / 1/71, 41 <br /> -.17 D. Treneporteia Pro <br /> 7. Transporter 2 Company Name m <br /> S. US EPA ID Number E. Stele Transporter, <br /> C)[ — Gf - F. Transporter's Phan 7 y <br /> 9. Designated Facility Name and SiteAddress 10. EPA IONu/nber G. State Facility's ID <br /> Dell 'nnG �e�cl � �Cr/U �i�Cl�+Iu�(O�( Iyrmil <br /> U <br /> [ H. F %a Phona��� /O�/ <br /> Z I �/ <br /> O 12. Cont note 13. Total 14, 1. <br /> LL 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> ¢ //'' / No. TYPe wt/VO4 <br /> L�✓us-fie U/ l.ZSM c-u5-1Y t7 E t - L,( , st <br /> E b. <br /> o R �J) c'^2 In <br /> EPA/Otho <br /> lJ State <br /> m A <br /> m T EPA/Other <br /> d <br /> N <br /> < O C <br /> p R State <br /> 0 <br /> op <br /> EPA/Other <br /> d' State <br /> Z <br /> w <br /> U <br /> w EPA/Other <br /> Z J. Adtlllional Deacripaona for Materials Listed Above <br /> IL K. Hendlin0 Codes for Wastes Listed Above <br /> a, 6. <br /> IL <br /> m <br /> C. d. <br /> Z <br /> O <br /> h 15. Special Handling Instructions and Additional Information <br /> G <br /> 2 <br /> S <br /> r <br /> J r <br /> a18. <br /> U 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, pecked, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> a international and national government regulations. <br /> N 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 1 have <br /> 0 determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to <br /> me which minimizea 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 /> U faith effort to minimize my waste generation and select the beat waste management method that is available to me and that 1 can afford. <br /> _� <br /> Printed/Type Noma. <br /> w <br /> ! Signature Month Day Year <br /> WTR 17. Transporter I Acknowledgiliffient of Receipt of Materials <br /> A Printed/T Name <br /> ¢ N a / Signature Month Day Year <br /> LL 3 �l 1 5 ) <br /> O p 18. Transporter 2 Acknowledgernefit of Receipt of Materials <br /> w <br /> to <br /> R Printed/Typed Name <br /> USignature Month Day Year <br /> 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 materials covered by this manifest except as noted in Item 19. <br /> T Frantic/ Name <br /> Y Signature Month Day Year <br /> DHA 8722 A(i/87) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> EPA 8]00-22 INSTRUCTIONS ON THE BACK <br /> (Rev.9-88) Previous editions are obsolete. To: P.O. Box 3000, Socroment0, CA 95812 <br />