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fForm designed far uaa on a!'4 ,2 Ifch t <br /> p typewriter). Toxic Substance•Control Div.&,, <br /> =ORM HAZARDOUS Aanerafor's US EPA Ila,o. Sacramento,Ceirtam <br /> 1fASTE MANIFEST ,i ti Manifest z. Pagelinformalion <br /> Document <br /> ti',.r`; in the shaded areas <br /> r}eTalor`,Namgnd May�jl nq tlddreas °ts not required by Federal law. <br /> �irw J�1 A. State Manifest Document Number <br /> 'S 1 <br /> �. Generator's Phones( � ) 9. State 4ener�tor'e ID <br /> 5. Tranaporter 1 com4anyµams <br /> U3 EPA ID Number C. Slafa Transporter's ID <br /> ',� , <br /> 7. Transporter 2 Company Name f - D. Tran,porler'a Plwne r f 4 <br /> 8. US EPA10Number E. State Insponer'a fD <br /> ' r 7 f F. Tranaporter'a Phone <br /> ^ 9. Deaipnaled Facility Nsms and r1its Addre� T <br /> ✓i j ,_.� 10. US EPA ID Number <br /> c r E.+ti rk f�( IG VJII a (1 stets Facitiry'.Ip <br /> } <br /> SFr,_., <br /> z N. Faclllfy'■II ~ <br /> k1 <br /> i C O 1 1. US DOT Descrrption(Including Proper Shipping Name,Hazard Claes,and ID Number) 12. Contalnera <br /> J s <br /> a a Quantify Unit <br /> IJ No. Type of 9 + a No. <br /> = G to e <br /> CC) ~ ETH <br /> MIR N M/I- <br /> o A , Stag <br /> TO tiL <br /> v EPA/Other <br /> --�� <br /> C\1 R c. <br /> m� Stats <br /> d. <br /> EPA f 000 <br /> Ii. U $}}tta <br /> Zu' EPA/OJher <br /> J. Additional Deecriptlons for Materials Listed Above <br /> -4 rJY` K. Handling Codas for Waatee LiI Above <br /> r <br /> ILL! a !� b. <br /> Z <br /> 0 <br /> Q 15. special Handling InahuOtiona and Additlonel Information <br /> 2Lli <br /> � <br /> pogujr: irW 'iu Ike. <br /> ,� Jt'l�;iLl�t{•111'!`�. �'F>;U`L'�.�'1�.1J�; C�eid�:gi,ihi�i itt+i� �•`�L"Is�IL'1'U!!, <br /> r <br /> 4 I8. <br /> U <br /> hereby declare Wall <br /> J GENERATOR'S <br /> d are classified,packed,packed,maarked+and labeled.and arethe <br /> 0 allrespects ilo propealgnment sI fully and AC.c condition for transport byu(Mtsly described highw y According to Applicable international and <br /> J <br /> a- national government regulations. ve Y proper shipping name <br /> OW) <br /> T a If 1 am a large quantity generator,I cerllfy that I have a program In place to reduce the volume and toxicity of waste generated 10 the degree I have determined <br /> 0 to be economically practicable and that I have selected the practicsble method of treatment,storage,or disposal currently available to me which minimize,the <br /> } present and future throat to human health and the environment;OR,If I am a small quantity <br /> 0generation end select the heal waste management method that is available to me and that I can afford. made a good faith effort to minimize my waste <br /> i w Printed/Typed Name <br /> i ¢ Signature <br /> Month Day Year <br />` W RT 17. Transporter 1 Acknowledgement 1pt of <br /> of RecaMaiarlale <br /> I z c• <br />! C N �Printod/Typad Name <br /> Signature <br /> LL SJ month Day Year <br /> w O nnaponor 2 Acknowledgement of Receipt of Material• r' <br /> R Printed/Typed Nama <br /> E 8lgnatyra <br /> TR Day Year <br /> 19. Discrepancy Indication Space <br /> r <br /> F <br /> C <br /> i I <br /> i L <br /> t 20, Facility Owner or Opanlor Cartlecatlan of receipt of hazsrdeua mModels covered by Ihlq a f a except as noted In Item I@, <br />' T <br /> Y <br /> PrintedrTYped lame f 9lgnature <br /> R ; iNonf � <br /> fsr <br /> DHS 8022 A(1188) ✓ r L" <br /> EPA 8700-22 Do Not Write Below his line - <br /> (Rev.9-88)Previous editions are obsolele <br /> GREEN: HAULER RETAINS <br />