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3tata N California-Health and Welfare Agency Department of Health Services <br /> —r,I pproved OMB No.2050-0039(Expires 9-30Toxic Substances Control Division <br /> Please print or type. (Form n <br /> designed for use oe 2-pitch fyP~lter). Sacramento,California <br /> UNIFORM HAZARDOUS 1 1. Generator'a US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> ASTE MANIFEST T �''D k ` (r U 1, 1,em�1 l of is not required by Federal law. <br /> 3. Go ator's Name anllal g Address A. State Manif at o ument Nu b <br /> -tow 1.NfJ US !y4k�"/4 <br /> 1 / r's <br /> 4. Generator's Phone(e7 � .r� e� ID <br /> 6. TranspCr}Doyen!Name 8. US EPA ID Number C. State Tranaporter's ID <br /> �C �-+ A � {� `) p D. Transporter a Phone <br /> It- <br /> 7. Transporter 2 Company Name e. US EPA ID Number E. State Transporter'a ID <br /> F. Transporter's Phone <br /> 9. Do ipnaedd Facility Na a and Site Address lo. US EPA to Number G. State Facility's ID <br /> ��c <br /> H. PhQne <br /> L) <br /> O< =¢✓ot iv/.r 4Avf1?0dU1l S� o`i �1 t U rl if D 11_4 51010 <br /> DQ 12. Containers /3. Total /a. <br /> 40 11. US DOT Description(Including Proper Shipping Name,Huard Class,and ID Number) Ouantity Unit Waste No. <br /> �Q No. Type Wt/Vol <br /> L 1 a. /`1 1rUUI N.0 • �/ 1 State /71 <br /> E '%K A4 C AM `/��'/ C �JOI, � 1 ) s /I C� / � EP" (a <br /> Nb A { \ els IVEL <br /> f0{' State <br /> EPA/Other <br /> i D <br /> R c. State <br /> €NVIRONMEN NAL HEALT14 EPA/Other <br /> Cut d _ . State <br /> Z <br /> W EPA/Other <br /> O <br /> W <br /> 0 J. Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> N ui�t r�'!r1,a TE, Ti�E.9r/r/Fit/%� $t vt7�, Oil b. <br /> W <br /> c. d. <br /> O 15. Special Handling Metructio and Additional Information <br /> H <br /> 2 - <br /> r.0 ='G, j%v , i f> -L /oP/i.--/ './:. . .� i. .cl4/ <br /> ..�/ <br /> J <br /> O i6. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> r 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 /> national government regulations. <br /> R If 1 am a large quantity generator,I certity 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.I have made a good faith effort to minimize my we . <br /> O generation and select the beat waste management method that is available to me and that 1 can afford. <br /> W Printed�/Tyd Name Signature Month Day Year <br /> W �T'J/KL IAvIS <br /> W T 17. Transporter 1 Acknowledgement W Receipt of Materials <br /> R <br /> Z <br /> A P d/Typed Nagy Sign ro Madh Day Year <br /> o g 1 DOO�r� Jc I / O <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> <<1 R Primed/Typed Name Signature Monts Day Year <br /> E <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 Signature Month Day Year <br /> DHS 8022 A(I 188) Do Not Write Below This Line <br /> EPA 8700--22 <br /> (Rev.9-88)Previous editions are obsolete. <br /> YELLOW: GENERATOR RETAINS <br />