Laserfiche WebLink
State of California-Health and Welfare Agency Department of Health Services <br /> Fom Approved OMB No.2050 <br /> r i -0039(Expires 9-30-9 Toxic Substances Control Division <br /> FTeyi6'prihf or type. (Form designed for use on elite pitch typewriter). Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generetora US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST A j Z ll Dou O t No <br /> WASTE et is not required by Federal law. <br /> 3. Generator's Name and Mailing Address 4 A. State Manif at o u nllNumD'erf <br /> =/✓Dy ELfci,1CN)6 53 <br /> bg- �1 a ZANCPVf7-4140 �/tk 1711' /YlAn.rtcA cA B. Slate Generator'sD <br /> 4. Generator's Phone( - Z - 10ildlf x F31y 5'5.334 r /„ <br /> i 31 112. <br /> 5. Transporter 1 Company Name 8. US EPA 10 Number C. State Transp er's ID Y <br /> n G iti A D qi RQ 591 Yjf—iii ( D. Tr°n°porter's Phone <br /> N <br /> m 7. Transporter 2 Company Name S. US EPA ID Number E. State Trenaporter's ID <br /> 8 F. Transporters Phone <br /> m <br /> B. Designated Facility Name and Site Address 10. US EPA ID Number G. Slate Facility's ID <br /> W4r21 I?4 C C Ilk L <br /> U ` <br /> 7 H. Facility's Phone <br /> 1/26V/1 <br /> � c, &02-/2 - Cl/G4 <br /> Z <br /> 12. Containers 13. Total 14. I. <br /> -to 11. US DOT Description(Including Proper Shipping Name.Hazard Class.and ID Number) Quantity Unit Weare No. <br /> Ja No. Type Wt/Vol <br /> �= a. IZ Cr pf�zi4 fZ t�C45 4V'r7 $ r�' /�. to 5 state / <br /> G EPA/Other <br /> p3 N , NA <br /> D R IsStat° <br /> N <br /> A EPA/Other <br /> T <br /> N HN 2 3 1992 R a State <br /> 8 ENVIRONMENTAL HEALTH EPA/Other <br /> d State <br /> EPA/Other <br /> U <br /> N J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z b. <br /> 41, <br /> Cx WA 57-e Wore Z Tlf.vi le.�,T SLvdc� d/ <br /> Wd. <br /> J <br /> Z <br /> z <br /> O <br /> H 15. Special Handling instructions and Additional Information <br /> Z Lt�fa.< i � lZ� ,�•1Y r1r� //)< 0reC TiVf c v ;h �IVff^— ltilhe v <br /> u, <br /> J <br /> O 8. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are 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 /> d I national government regulations. <br /> to I certify that I have a program in lace to reduce the volume and toxicity of waste generated to the degree I have determined <br /> 0 If I em a large ally practicable hu and that I have t elected the nt;OR.if I method of treatment,storage,or have <br /> m al currently available to ma which minimizes the <br /> present end future threat to human health and the environment;OR.it I em a smell quantity generator,1 have made a 9oatl faith effort to minimize my waste <br /> 0 generation and select the beat waste management method that la available to me end that I can afford. <br /> Z Sigmt -""—� Monts Day Year <br /> (W7 Printed/Typed Name <br /> 0 � 019010 <br /> UJIA f <br /> W T 17. Trensporter 1 Acknowledgement of Receipt of Materials <br /> Z R S net Month Day Year <br /> Q A Printed/Typed Name <br /> N <br /> O S <br /> W 18. Transporter 2 O Ackn ledpement of Receipt of Materials <br /> TPrinted/Typed Name Signature MpnM Day Year <br /> E <br /> Z_ <br /> FA <br /> /9. Discrepancy Indication Space <br /> I20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted In Item 19. <br /> Ty Printed/Typed Name Signature Month Day Yaar <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 RETAINS <br />