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.rareorcalllornia�fealth and Welfare Agency <br /> Form Approved OMB No.2050-0039(Expires 9,30-9 Department of Health Services <br /> Please print or type. (Form designed for use on elite Toxic Substances Control Division <br /> p's US E Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID Na. <br /> WASTE MANIFEST Manifest 2. Page 1 <br /> o u nt�A Information in the shaded areas <br /> 3. Generator's Name and Mailing Address l rG' of / is not required by Federal law. <br /> A. State Manifest Document Number <br /> .BfQi;i ul" (.k. <I, >rI e. StateB. 9tete Ge <br /> 0 S. Transporter 1 Company Name ' <br /> N 6. <br /> US EPA ID Number I <br /> C. State Trensporter's ID <br /> T. Fl.porter'a Phone <br /> tp 7 Transporter 2 Company Name d +' <br /> 8. US EPA ID Number E. State Transporter's ID <br /> O <br /> F. Transporter's Phone <br /> 9. Designated Facility Name antl Site Address 10 <br /> JUS EPA ID Number <br /> G. State Facility's ID <br /> h-:A i4h'I-d4^O ::ST4 Vii��F. <br /> H. Facility's Phone <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14, <br /> a. (.,. - _ t No. Type Quantity Wt/Unit <br /> West.No. <br /> State <br /> G <br /> �. E <br /> E b. ,(. �•. FY r'f t ') -� 7 G� 1 J' 0f EPA <br /> /Other <br /> R l9 <br /> A State <br /> C9 T <br /> N R c. EPA/Other <br /> OP <br /> State <br /> ir d D �� EPA/ether <br /> F <br /> W JUN 2 p 1989 State <br /> U <br /> W EPA/Other <br /> m J. Additional Descriptions for Materiels Listed Above <br /> O9NIRJNfchENTAI"tIEALTHK. Handling Cotles for Wastes Listed Above <br /> OL <br /> - zc <br /> w 7".LER111/S`R`✓ICES a. b. <br /> J <br /> Q c. d. <br /> Z <br /> O <br /> Q15. Special Handling Instructions end Adtlitional Information <br /> Z <br /> W <br /> S <br /> F <br /> J <br /> U <br /> 16. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by Proper shipping <br /> –t <br /> and are classified,packed.marked.Intl labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> d national government regulations. P Aping name <br /> N <br /> It I am a large quantity generator,I certify that I have a program in place to reduce the volume atmentstorage,or disposal currently available to me which minimizeand 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 fire , s 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 waste <br /> U generation and select the beat waste management method that is available to me and that I can afford. <br /> Z <br /> ID Printed/Typed Name <br /> Signature <br /> Lu Month Day Year <br /> W R 17. Transporter 1 Acknowledgement of Receipt o1 Materials <br /> 4 A Printed/Typed Name <br /> N �/� Signature <br /> LL P .... V Month Day Year <br /> O ,< <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> W <br /> U <br /> T Printed/Typed Name <br /> E Signature <br /> Z Month Day Year <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I 20. Facility Owneror Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T <br /> y Printed/Typed Name <br /> Signature <br /> Month Day Year <br /> DHS 8022 A(1/88) <br /> EPA 8700-22 Do Not Write Below This Line <br /> (Rev.9-88)Previous editions are obsolete. <br /> YELLOW: GENERATOR RETAINS <br /> I� <br />