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State c 'alifornla-Health and Welfare Agency <br />E,..m AY nved OMR No. 2050-0039 (Expires 9-30-88)_ <br />Department of Health Services <br />Toxic Substances Control Division <br />Sacramento. California <br />lase^ 111t <br />or type. Form deal ned for use on elite 'h type writer). <br />1. Generator's US EPA ID No. Manifest �2. Page 1 .Information in the shaded areas <br />UNIFORM HAZARDOUS Document No. <br />of is not required by Federal law. <br />WASTE MANIFEST ArNn r) <br />3. Generator's Name and Melling Address A. State Manifest rum°nlNumberer <br />L r NC ZJ <br />0r0 R. Slate Generator's ID <br />� <br />I <br />4.�~r� <br />Phone (r J c ( _ - <br />5. Transporter 1 Company N ma a. US EPA ID Number <br />C. State Transporter's <br />D. Transporter's Phone <br />_,f <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID <br />F, Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />CtjUnICA 1- WnsTE- rf)ACAMC14r-E�NC <br />H. Facility's Phone <br />kc-f-t-Lumn� C I C A <br />12. Containers <br />13. Total <br />Quantity <br />14. <br />Unit <br />1. <br />Waste No. <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />No. Type <br />Wt/Vo <br />°�YVTAtT�iNATLL �jplL. wITN g)CtfZOLC_UM <br />State <br />G <br />I1("`JC►'iZ'�GAi <br />EPA/Other <br />E <br />11V <br />N <br />ate <br />E <br />b. <br />' <br />R <br />A <br />EPA/Other <br />T <br />O <br />Slate <br />R <br />c <br />EPA/Other <br />State <br />d. <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />b, <br />VoeLanjcs, <br />) <br />';i <br />a. <br />C. <br />it. <br />/s/Vor�,yc`r�6i3K�s <br />�.iLI D11210,Q <br />15. Special Handling Instructions and Additional Information <br />`Q <br />t�i1'-VoTCjC7n ,-r CILUTN r A)G <br />18, <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are lolly and accurately described above by proper shipping <br />transport by highway According to applicable <br />name and are classified, packed, marked, and labeled, and are in all respects in proper condition for <br />international and national government regulations. <br />If I am a large quantity generator, 1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have <br />treatment, storage, or disposal currently available to <br />determined to be economically practicable and that I have selected the practicable method of <br />me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator. I have made a good <br />faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. <br />Printetl/Typed Neme <br />Signature Month Day Year <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A <br />N <br />Printetl/Typed Name <br />Month Day Year <br />Sig store /j' y . <br />S <br />' S' <br />P19. <br />0 <br />_ <br />Transpdrter Acknowledgement of Receipt of Materiel° _ — -- <br />TPrinted/Typed <br />Name <br />Signature it -I <br />V14 <br />Month Day Year <br />, <br />E <br />ZI Ail 1' <br />19.'Discre ency lndicetldn p ce <br />F <br />NOV 21 1988 <br />A <br />C <br />6V',i�:�OiJPA=PJTAl I'I1 i T <br />l <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest beyit'ae del' 1 Idem 19. <br />T <br />Printed/Typed Name <br />Signature Month Day Year <br />Y <br />I I I I I I <br />DMS 8022 A (1 /87) YELLOW: GENERATOR RETAINS <br />EPA 8700-22 <br />(Rev. 9-88) Previous editions are obsolete. <br />INSTRUCTIONS ON THE BACK <br />IN CASE OF AN EMERGENCY OR SPILL, CALL THE NATIONAL RESPONSE CENTER 1-800-424-8802; WITHIN CALIFORNIA CALL /800-8527550 <br />