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I a Of lrol ed O No.2 and Welfare Agency <br /> See Instruct�Fronl <br /> s an Ba k of Page 6 Department of Health Services <br /> Form Approved OMS No.205b�--W39(Expires 6-30-91) <br /> Please print or type. Form designed for use on ell -pffch typewriter). and of 7 Toxic Substances Control Division <br /> Sacramento,California <br /> UNIFORM HAZARD©US (�enerator'a us EPA Ip No. _ a 1ra91�'- z Page s1— -- <br /> WASTE MANIFEST I Document No. Inforniation in the shaded area, <br /> Of I is not required by Federal law, <br /> 3. Genaretor'a Name and Melling Address <br /> A. State Manifest Docum I Nu be� <br /> �z. ss P,Vic r,/ �{ � IL-7+ 'I �0 � 4 8 0 <br /> ASaZ Al. 460P A �UI� `60 , ✓r>Ct5 (C7�C Oeneralor"e fp <br /> 4. Generator's Phone ! ) L/ a 7 a �� <br /> Lo 5. Transporter 1 Company Name T 6. US EPA 10 Number C. 51ate Traneparter's ID + <br /> un -711 3 <br /> h, Tr�e�Aali•r'r I'nen■ bq � <br /> IO <br /> 7. Transporter 2 Company Name LIP E, State Transporters ID <br /> 6. US EPA. f0 Numher - <br /> O <br /> F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA 10 Number 0. State Facility's ID <br /> J C�l[3Sc7/u' t`'/YY/Ro/t'l�/+dTf�C. <br /> J EN © <br /> D f' C6Mk"E4?C!!gr Il%, D R 3d� Z l <br /> H. Facility a Phone <br /> Z - '33 o D 9 Po P J0 l -717 <br /> /-- 60- <br /> 12. <br /> Q <br /> rr <br /> Q 11, US DOT Descripllon(Inc#uding Proper Shipping Name,Hazard Class,and 1D Number) 12. Containers t3. Total 1ni <br /> Quantity Unit Waste No. <br /> p pp�j �y / 1n w No. Type wl�vol <br /> e. I'VON RCRH HA�4R�.5 1,(QtAjD Ars-rr Slate <br /> Z I�1 / r i her�3 -- <br /> G _ <br /> i " 4S 7? 2d I- . H a u s t <br /> E b- <br /> ni R State <br /> 8 A <br /> cc T <br /> O EPA10ther <br /> c <br /> sv <br /> o R C. <br /> gStele <br /> ap <br /> EPA/Other <br /> a d <br /> w <br /> i- `=Isle <br /> Z <br /> Lu <br /> 0 EPA/Other <br /> wN <br /> X J. AddNlonal Daasrlptlanr for MeleHele Listed Above �, K. HrhNnnp Gedea far Wastes Lrnl-eddXi hove <br /> CO <br /> f-�B+SO tlN SRL�fS r `!r �Grb- 1 J 1 b. <br /> Lu <br /> Z5/-TE e ADVRE6s �' O'c 31 s. ,J I oc `-r©f�t; ! f vE. c. d. <br /> Z RIPONLD <br /> 15. Special Handling Instructions and Additional Information -�- <br /> d <br /> Z <br /> w <br /> -j ACOMIC2 VE 01-oTgAE5 &n t8 f O <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 inlarnationat and <br /> a national government regulations. <br /> 17 <br /> (r 11 1 am a large quenfity generator,I c"Ily that I have a program in place to reduce the volume and toxicity o1 waste generated to the degree I 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 /> } present end lulure threat to human health and the environment;on,if I am a small quantity generator,I have made a good fallh effort to minimize my waste <br /> L) generation and select the best waste management method that Is available to me and that I can afford. <br /> Z <br /> UP Printed/Typed Name Signal a Month Day Year <br /> cc <br /> w 1 �� <br /> W T R 17. Transporter 1 Acknowledgement of Receipt o1 Materiels <br /> ZA Printed/Typed Name Sign a <br /> N O zv} /�+,r g Month Day Year <br /> 0 S µ <br /> Q p <br /> LL) 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed7Typed Name Signature <br /> (.J IMoin7h Day Year <br /> E <br /> Z <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> It 20. Facility Owner or Operator Certification of receipt of hazardous materials covered h Is manifest except as ata n Item 19. —I <br /> T Act) Fy/l _ I <br /> y PrintedlTyped ams Signature ��"� f _ M7rf ear <br /> )HS 8700o022A <br /> PA Oto Not Write Below This Line <br /> - <br /> aev.8.89)Previous editions are obsolete. <br />