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State of California--health and Welfare Agency <br /> Form Approved OMB No.2050--0039(Expires 9-3091' Department of Health Services <br /> Please print or type. (Form designed for use on elif pitch typewriter). Toxic Substances Control Diviaicr <br /> UNIFORM HAZARDOUS - enerator a us EPA ID No. Manifest 2. Pegs 1 Sacramento,California <br /> WASTE MANIFEST Document No. Information in the shaded areas <br /> 3. Generator's Name and Meiling Address of is not required by Federal law. <br /> 6) WISNER GUILM A. State Manifest Dgpu N b r <br /> 7��1r,7� WIIlow 88Z <br /> 'G6719� ; A3 Z B. 9tUe Generator's ID <br /> 45 <br /> a. cane.for o d'(' <br /> �i 6. Transporter 1 Company Name e. US EPA ID NumberJIF. <br /> ate Trena orter's ID <br /> a H H Shi SerV Ice 10 14 17171 eneporter a Phone <br /> 7. Transporter 2 Company Name e. US EPA ID Numberate Transporter's ID <br /> ansporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Numberate FecIIKy'a ID <br /> H i H ShipSeMco CanpwW220 China Basin Street IAInIal <br /> ,< San Francisco, CA 94107 r <br /> _• $- 11. US DOT Description(Including Proper Shipping Name,Hazardlass,�and ID Number) -&Cility's Phone <br /> 12. Containers 13. Total 14. 1, <br /> Quantity Unit Waste No. <br /> No. Type Wt/Vol <br /> f17F' a W"M TAW <br /> Stets <br /> GE N4 199J ODbt#i5,7t81E LIgJI© NX12 <br /> 3 N EPA/Other <br /> E b. <br /> R State <br /> A <br /> N Q EPA/Other <br /> v R c. <br /> Q ' � State <br /> 3S EPA/Other <br /> ird <br /> ,,, grate <br /> w <br /> U <br /> U! EPA/Other <br /> I. 2 J. Additional Be K. Handling Cedes f <br /> .grlptlons for Materiel.Listed Above or Waetee Listed Above <br /> N 6�TY AM p RUNIT&R OIL STC FVO TAW WITHa. IT. <br /> 401"I'lMIJAMY TQ Maw wo) M404 wSlaw, alas <br /> . ,. <br /> LJ <br /> ie J g• d. <br /> Z <br /> 0 <br /> r- 16. Special Handling Instructions end Additional Information <br /> i, Z TAC P49ADVAL SIM S80 North Sacra to Street <br /> PRID71ICTNE GewAS R"IRED, Lodl, California <br /> J <br /> J <br /> I V 18. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J and are classified,packed,marked,and labeled,and are In all respects in proper condition for transport by highway according to applicable International and <br /> g� national government regulations. <br />�' fZ 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 determined <br /> 0 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 /> present and future threat to human health and the environment;OR,it I am a small quantity generator,I have made a good faith effort to minimize my waste <br /> 4 U generation and select the best waste management method that Is available to me and that I can afford. <br /> Z <br />,'. lidPrinted/Typed Name Sfg na e i s -- <br /> / Month Day Year <br /> r� <br /> W a� WIC iiK <br /> y <br /> W T 17. Transporter 1 Acknowledgement of Receipt of Material. -v-� <br /> A Printed/Typed Name 9lgnature �_ ^ <br /> g, S pN.iaysar PIR <br /> ` Month Day Yeer <br /> ° P ail .GV'Y� PIENIIIIIL 6R \. _.. - <br /> W 0 18. Transporter 2 Acknowledgement of Receipt of Materials 0 4 21l!144 <br /> U R Printed/Typed Name Signatures <br /> E Month Day Year <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 <br /> y Printed/Typed Name <br /> Signature Month Day Year <br /> DHS 5022 A(1/88) <br /> EPA 8700-d2 WDo Not rite Below This Line <br /> (Rev.9.88)Previous editions are obsolete. YELLOW: GENERATOR RETAINS <br />