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orlealth andWelfareAgency Department of Health Services <br /> No.2050-0039(Expires 8-30-91) Toxic Substances Control Division <br /> I qpe. (Form designed for use on efffe(' itch typewriter). Sacramento.California <br /> �(NIFORM HAZARDOUSwf tor's US EPA ID No. Manifest Papa 1 Information In the anadea a sae <br /> WASTE MANIFEST ' T� U y �t "�°" or is not required by Federal law. <br /> 3. Gener ' Nam`/e and Mout. Address A. State Manifest Do ument Numb r <br /> lJ 1- 7-e- ii rY tr <br /> O Rtl---'=;/.,7c. , �Vr .% $8 324 <br /> /✓r(,/r V, � ln. . V-30 g R. Stete_Generelor'a ID <br /> 4. Generator's Phone LVOY) iO H(�}J? � Q . <br /> 8 Ort. «,'CPKpny Nam. /1 a. A A U$ EP D uler C. State Transporters <br /> Phan ID <br /> N <br /> ,``a•.Ayal (W~ jVa{qI D. Trenaporter'a Phone <br /> m 7. Transporter 2 Company Name 8. US EPA ID Number E. State Tranaportar's ID <br /> 0 <br /> 0m F. Transporter's Phone <br /> 1 9. Daegnoted Facility!!�;and Site Aera 10 US EPA ID Number G. $uto F It b ID <br /> H. r, my- P ng <br /> 2 3 cv/552(/ - <br /> 10 12. Containers 13. Total 14. 1. <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Claes,and ID Number) Quantity Unit Waste No. <br /> lQ No. Type <br /> . 1 Wt/Vol <br /> State,� L-de j <br /> I �Z. <br /> N OA?A - C / / lln I yEPA/19VIO <br /> .N ER b. f j,?0IA1P -�' .� Stagy.N. <br /> a 6100/- AF. tiA 'rkl/ 0 r ala <br /> N R C. Stet. <br /> R <br /> e l E C E I V "�, L EPA/Other <br /> wd, <br /> 1- <br /> State <br /> Z <br /> v FNVIRONMENTAL HE ALT EPA/Other <br /> w <br /> rn J. Additional Descriptions for Materials Listed Above �PESK. Handling Codes for Wastes Listed Above <br /> Z <br /> d <br /> rn07_a.__.. ,__.._ b. <br /> a?, <br /> o C. a <br /> o Al 03450 s <br /> a <br /> 15. eciai H lin InsJt uc0one and Additional Inlorm tion 0. , ('UNr"elf//)/ti;1frGSo/li8fo <br /> Llel, rY'Fj ) 4* Y/ ;i/ ./Jai :r'' 1 <br /> J <br /> V 19. � <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment aro fully and accurately described above by proper shipping name <br /> 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 /> y national government regulations. <br /> If I em a large quantity generator,1 certify that I have a program in place to reduce thevolume and toxicity of waste generated to Me degree 1 have dalermined <br /> p 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 smell quantity generator,I have made a good faith effort to minimize my waste <br /> U generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> PrintsT ped Name Signe Month Day Year <br /> Ulf y .N 0.4 V/ 3 r?1 G r r 7 9a <br /> LRT 17. Transporter i Acknowledgement of Receipt of Materials <br /> Q A Print me - Siokalure - 1 � �,�L,y, �'�• �,�- _ Monts Dey Year <br /> IN <br /> Op <br /> JI O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> T Primed/Typed Name Signature - Month- 'Day Year <br /> i <br /> E <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. FaciBty Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in hem 19. <br /> T <br /> Y Printed/Typed Name _. Signature. - Monts Day Year <br /> -HS 8022 A(1/88) Do Not Write Below This Line <br /> PA 8700-22 <br /> lay.9.88)Previous editions are obsolete. <br /> YELLOW: GENERATOR RETAINS <br />