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,414alth and Walters Agency <br /> SMB No.2050-0039(Expires 9-2r Department of Health Services <br /> .r type. (Form dealgned for use o. 2-pitch typewriter). Toxic Substances Control Dlvlelon <br /> Sacramento,California <br /> - UNIFORM HAZARDOU Generator's US EPA ID No. Manifest z. Pepe t <br /> ,1—.'--WASTE MANIFEST " %l r� :' ''� I. / } 1 rp come 00. / Information In the shaded areae <br /> of is not required by Federal law. <br /> EGert,.W a Neme aqqd Meiling Atl�Sesa <br /> A„ / p p. 1_ : rt' A. Slate Manifest p}�.���^�� `�`�{� <br /> 1,` l i,y / B. Stele Geppereis ID'e Phone( t `Y) : { i [>- )' f + G Ger 1 Company Name / 8US EPA ID Number C. State Trensponer's IDU G (r �f y; <br /> G ( D. Transporter'a Phone _13 <br /> tg ]. Transporter 2 Company Name 9. US EPA ID Number <br /> O E. SlelaSrenaponer's ID <br /> $� 9. Designated Facility Name and Site Addre.a F. State Facility's <br /> Phone <br /> J ) 1. ` 14 US EPA ID Number G. State Facillty'a ID . - <br /> f- 1 f i' "/ r•, I) J9 e� ../;y�,I rr H. Faclllty'a Phone <br /> 1 11 <br /> N J_0 11. US DOT Description(Including Proper Shipping Name,Hazard Claes,and ID Number) 12. Containers 13. Total <br /> �< No. Type <br /> Quantity Unit Waste No., <br /> �U a :i ,. 7 :... - :. . !• e:: r � <br /> Wt/Vol <br /> = State <br /> 00 E / <br /> 3 N ✓_.: EPA/Other <br /> E b. <br /> N R <br /> A Siete <br /> C? T <br /> n O EPA/Other <br /> a R C. _. <br /> g j State <br /> EPA/Other <br /> r <br /> Z state <br /> 0 <br /> W EPA/Other <br /> Z J. Additional D...1glions for Main i/ 11 Llstetl Abave <br /> O I ^ " i - , '^-i<" / ,• : ?:7�✓1\ C� C 1,} A:.�/ )f^f ,K. Han Codes for Waste,Listed Above <br /> /23 y 1 is / !L`. t.4 .. e. D. ......... _........ <br /> _ <br /> 0 <br /> 15 Special Handling Instructions and Additional Information ., <br /> < 16. .ver'% �1 <br /> GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully^ nd accurately described above by proper shipping name <br /> and are classified,packed,marked,and labeled,and <br /> are <br /> in ell respect.in proper conditlion for baby highway according to applicable international and <br /> a national government regulations. <br /> 0 <br /> ¢ If I em.large quantity generator,I certify that I have a program in place to reduce the volume a xic�tTy <br /> O to be economically practicable entl that I have selected the practicable method of treatment,storage,or d spealtcuvf <br /> currently available t bay.determined <br /> me which Minimize.the <br /> l quantity generatorI have made a good faith effort to minimize my waste <br /> present and future threat to human health and the environment;OR,If I em a small U generation and select the beat waste management methotl that le available to me and that I <br /> .can_arfoud <br /> W rn ,N1 ` <br /> C O ' Signature Mombil, Day Yee <br /> K-)Z <br /> wR f 7. Transporter/ Acknowledgement of Receipt of Materiels <br /> Q A Printed/Typed Name <br /> Signature t• Month Day Year <br /> I.I. g fir= & ! I/ .:� f <br /> w O 18 Tranapo er 2 Aeknowletlgement ofReceipt of Material. <br /> N <br /> J <br /> U T Printed/Typed Name Slpnature <br /> MFR Month Day Year <br /> 19. Dlecrepengy Indication—Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I 20. Facility Owner o.Operator Certiilcation of receipt of hazardous materiels coveretl by thio manileet except as noted in ttem 19. <br /> T <br /> y Pdnted/Typed Neme <br /> Signature Month Day Year, <br /> DHS e022A(1/e6) Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9-68)Previous editions are obsoleteYELLOW: GENERATOR RETAINS <br /> . ' <br />