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:ilwe of California—Mealth antl Wellum Agency Department of Naeltn aarvm,,. <br /> Form Approved OMB No.2050-0039(Expires 9-30-a9) Toxic Substances Control Divisw�i <br /> Please rim or type. Form designed for use on elite ildhoitch typewriter). Sacramento.CalllonlL.. <br /> UNIFORM HAZARDOUS IlWGenerataes US EPA 10 No. Manifest 2. Page I Information in the shaded areas <br /> WASTE MANIFEST /,J A U (,,,, �� - Document No. of is not required by Federal law. <br /> 3. neralor's Narpe end Mailing Address A. Stela Manifest Document Number <br /> � i eft +,, /e'1; <br /> a. Stale Generator's Ip <br /> 4. Generalor's Phone h.• •/) �,' (ILI � 3,)4/ <br /> 5. Transporter 1 Company Name e. US EPA ID Number C. Slate Trane oger s ID ' <br /> '/ _ / 9 ,� ) D. Transporter',Phone ') .0 '- _ <br /> s 7. Transporter 2 Company Name 8, S EPA ID Number E. State Tranapmar'e I O <br /> m <br /> o j;�i.- i ,,,; .� . � � / / � F. Transports'a Pnon r <br /> 0 <br /> � 9. Designation Facility Name and Site Address 10. US EPA ID NumOer G. Slate Facility's Ip <br /> J <br /> H.-F cilgy's Phone <br /> Z 12. Coalamera 19. <br /> otal 14. I. <br /> D <br /> O 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> IL No. Type WI/Vo <br /> a. <br /> U li(/ii» G•l C"r, •,G(„4 bIC �I it �1C'j Staff <br /> Z G <br /> E E /Oma <br /> r N <br /> 3 E b. State <br /> R <br /> A EPA/Other <br /> m T <br /> o H c. Stale ._... <br /> 0 <br /> 0 <br /> 1p EPA/other <br /> W d. $tale <br /> Z <br /> Z <br /> U 1 EPA/Other <br /> 00y J. Additional Descriptions for Materials Listed Above lir K. Handling Codes for Wastes Listed Aleve <br /> O¢ a d.. <br /> Vi <br /> QZ <br /> O <br />�'G 15. Special Handling Instructions and Additional Information <br /> WMyy�Z <br /> H <br /> J <br /> J16. <br /> UGENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> international and national government regulations. <br /> ra <br /> If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated 10 the degree I have <br /> determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to <br /> O me which minimizes the present and future threat to human health and the environment: OR. if I am a small quantity generator. I have media a flood <br /> laith effort to minimize my waste generation and select the beat Waste management method that is available to me and that I can afford. <br /> U <br /> Z Printed/Typed Name Signature Month Day Year <br /> cW7 <br /> ., <br /> 2 T 17. Transporter 1 Acknowfedp ent of Receipt of Materials <br /> lb H <br /> Z A Printed/Typal Name g signature /n;, Month Day Year <br /> S N <br /> u. <br /> O O 18. Transporter 2 Acknowledgement 0l Receipt of Materials <br /> N T Prinretl/Typ ams Signature r' Monfn Day Year <br /> 19, Discrepancy Indicalmn pace' <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 /> Printed/Typed Name Sl9nature Month Day Year <br /> Y <br /> DHS 8022 A(1/87) INSTRUCTIONS ON THE BACK <br /> EPA 8700-22 YELLOW: GENERATOR RETAINS <br /> (Rev.9-66) Previous editions are obsolete. <br />