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Department of Health Services <br /> State of California-Health and Welfare Agency Tonic Substances Control Division <br /> Form Approved OKW No.2050-0039(Expires 9-3091 Sacramento,California <br /> Please print or type. (Form designed for use oa elite ch typewriter). <br /> 1 Generator's US EPA ID No Manifest 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS Document No. of , is not required by Federal law. <br /> WASTE MANIFEST <br /> A. Siete Manifest Document Number <br /> 3. Generator's Name and Mailing Address 8 Q i <br /> B. State Generator's ID <br /> 4, Generator's Phone( ) <br /> 0 6, US EPA ID Number C. State Transporter's ID <br /> b 5. Transporter 1 Company Name� D. Treneporter's Phone <br /> r <br /> n 7. Transporter 2 Company Name <br /> S. US EPA ID Number E. State Tranaportar's ID <br /> OR F. Transporter's Phone <br /> 0 <br /> m G. State Facility's ID <br /> 9, Designated Facility Name and Site Address 10. US EPA ID Number <br /> i l l l l l l l l <br /> H. Facility's Phone <br /> Q <br /> �U <br /> a <br /> Z 12. Containers 13. Total 14. I. <br /> ¢ Quantity Unit Waste No. <br /> O 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) No. Type Wt/Vol <br /> LL <br /> J <br /> State <br /> 2 a. <br /> U <br /> Z G EPA/Other <br /> = E <br /> 0 3 N State <br /> E b. <br /> R EPA/Other <br /> A <br /> m T <br /> < O State <br /> O <br /> R C. <br /> EPA/Other <br /> OP <br /> ti . <br /> State <br /> ¢ CL <br /> w <br /> Z <br /> EPA/Other <br /> W <br /> U <br /> wHandling Codes for Weatea Listed Above <br /> 0J. Atlditional Descriptions for Materiels Listed Above a a. It. <br /> O <br /> a <br /> ¢ <br /> J <br /> Z <br /> Z <br /> 0 15. Special Handling Instructions and Additional Information <br /> Z <br /> Z <br /> J <br /> < 16. <br /> U <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this open consignment omniaro fully and accurately described above pl 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 am a large quantity generator,I certify that I have a program in place to reduce the volume end toxicity of waste generated to the degree I have minimizes <br /> ¢ 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 /> 0 present and future threat to human health and the environment;OR,if I am a small quantity generator,I have made a good faith all ort to minimize my waste <br /> generation and select the beat waste management method that is available to me and that I can afford. <br /> O Month Day Year <br /> Z Printed/Typed Name Signature <br /> C7 <br /> W <br /> WT 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Z R Signature Month Day year <br /> A Printed/Typed Name <br /> N <br /> O S <br /> P 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> U RPrinted/Typed Name <br /> Signature Month Day Year <br /> E <br /> Z <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted In Item 19. <br /> T Printed/Typed Name Signature MonthIRETAINS <br /> Day <br /> V <br /> DHS 8022 A(1/88) Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. YELLOW: GENERATO <br />