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State of California—Health and Welfare Agency c ,{i-.lIJ._ Department of Health Srr:'c <br /> Form'Approved OMB No.2060--0039(Expires 9.30• ,�7,('�'1 +� Toxic Substances Control r <br /> Please print or type. (Form designed for use.on.sll pitch typewriter). Sacramento,C,I:! n <br /> UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest 2. Paget Information in the shaded areas <br /> WASTE MANIFEST <br /> Document No. <br /> of is not required by Federal law. <br /> 3. Generator's Name and ailing Address A. State Manifest D n <br /> y bV �, a.�/a r !veli! r;'<.; ,10-91740 <br /> p. State Generator's ID <br /> 4. Generator's Phone <br /> ..J�_.. LL -- <br /> n 6. Tr neporter 1 ompany Name 8. US PA ID Nm her - •tale ranaporlar's D <br /> m r ransporter'e Phon ✓ ' <br /> 1. <br /> m 7. transporter 2 Company Name 8. Use FPAFPA I :"'.le Transporter' J <br /> 0 1 I I L 1 1 1 1 1 1 )_ Porter's Phone <br /> 00 <br /> 9./jQesignated Facility Name and Site Address 10. US EPA ID Number Facility's ID <br /> \flail;; 1 '!YI a�tt lc/ � I ,,./ .. a�l ✓}I _ iPlo�st( [.drt•�� ' !'1, I(�I <br /> 12. Currin finals 13. Total 4/4. I. <br /> w� 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waslo N <br /> �u- No. TYpe wt/vol <br /> �y'r0 a. State <br /> W/Z G W(f"'�. C`.)fI�G„� •�'r i����U <br /> M E <br /> N67 J_1 '71, 1 I <br /> NR b- / 1 Slate <br /> A <br /> T - EPA/Other <br /> e O <br /> V R c.' State <br /> RE <br /> EPA/Other <br /> 2t JF -4 <br /> Z d. NOV 2 7 1999 State <br /> EPA/Oinor <br /> w i _ <br /> WENVIROI`dMENTA ; T; I _..L_l I_- <br /> rn J. Additional Descriptions for Materials Listed Above E ^.•lin Codas for Wastes Listed Above <br /> Z / <br /> p PERcrI(1 g b. <br /> d. <br /> O <br /> 16. Special Handling Instructions and Additional Information <br /> Z <br /> J _....._.....__ <br /> < 18. <br /> U <br /> J 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 /> 0- national government regulations. <br /> cc 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 /> 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 and future threat to human health and the environment;OR,If I am a small quantity generator,1 have made a good faith effort to minimize me waste <br /> Ci geratelldn and select the best Waste management method that is available to me and that I can afford. <br /> U Printed/Typed Name Signature , �J,��° Month Day y <br /> Wl..✓J' f rr7 ..rYi ;,�•/r 4 ' 2 r <br /> w /T 17. Transporter'l Acknowledgement of Receipt of Materials <br /> R _ <br /> 4 A Printed/Tye Name Signator /� �" Month Day <br /> UL S / <br /> P <br /> uu O 18. TTIMbPofter 2 Acknowledgement Receipt of Materials <br /> UT Printed/Typed Name Signature Month Day 1 <br /> E <br /> Z R <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 excc. u:,,joie:: in Item 19. <br /> y Printed/Typed Name Signature Month Day Y, <br /> DHS 8022 A(1/88) Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9.88)Previous editions are obsolete. <br /> YELLOW: GENERATOR RETAIN;. <br />