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to oiCalifornia—Health and Welfare Agency �-:' <br /> M Approved OMB No. 2050-0039(Expires 9 30 88) DepaNlaesta1NIlaM oarvlcp` <br /> . . Toxic Subsb,,M C "DMWM <br /> ase print or type Form designed for use on elite12- itch t r. Socramewil.California <br /> UNIFORM HAZARDOUS 1 Generator EPA ID No. Manifest g, pool lotwm�tla�p <br /> WASTE MANIFEST Document No. <br /> of to!L not.fOqul(eQ. <br /> 3 Gnv rn I.,'.Na and Madin/p Add ree9 �4 y� A. State Manifest Y <br /> A ��/ "fat fevrl <br /> 14114v,- �/ <br /> II4v,— CIA-7 S�.2y S State Osn rst <br /> 4. Generator's Phone acq 76 <br /> 5 1r nsp rter I Comn ,Name 6. US EPA ID Number C. State ran., Nar <br /> 0 pa ,t}•! <br /> ' A D. TrsnepPr,or.P ,Cy'; <br /> ]. Transposer 2 Company Name 8, U9 EPA ID Number E. male Tralleptl/ter +'�,.' <br /> t; <br /> . TrNaPprtar'� -;r <br /> 9. Desipnatetl Facility Nem//e/�epd Sile Atltlrasa f0. US EPA ID umber O. State FeyUpy'! r ' <br /> M <br /> H. Fecl'y''Ph, e•'+.:,1 :.,.t: ..; <br /> 12. Containers 13 Tot I 14. + I <br /> I I. US DOT Description(Including Proper Shipping Name,Hazard Class.and ID Number) Quantity Unit <br /> //--�� No. tTylps Wt/V z <br /> a. L✓U.S4c Oil C-4mbcs1i6le L,CL,iJ <br /> b N <br /> n <br /> 1. <br /> 7 <br /> C. <br /> LJ— <br /> d. <br /> x <br /> P'i(+ <br /> try,: <br /> P. <br /> J. Additional Descriptions for Materials Listed Above - K. Hilliplaq0. <br /> .y - <br /> 1 T { ✓ <br /> S :ri• (yzy ti; r <br /> e <br /> ly i1 ✓i <br /> 15. Special Handling Instructions and Additional Information <br /> 4 , <br /> 18. _. <br /> I,in:n <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fullyend accurately described above by propaT <br /> name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway aGGofding�q a�t i r, <br /> international and national government regulations. <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 Io the tlegrKyVjrP #' <br /> determined to be economically practicable and that 1 have selected the practicable method of treatment, storage, or dispoad ocurrentlytda e;Alliin tp. #� <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 rgatlR <br /> faith effort to minimize my waste generation and select the beat waste management method that is available to me and that 1 can afford. <br /> Printedp Name SI nelur <br /> g NonM!i YIN 1 <br /> ell <br /> 17 i7ansporhir 1 Acknowledgem nl of Receipt of Materials <br /> Printed/Ty ed ams Signature "Goal yw <br /> l <br /> 11 <br /> ta. Transp der 2 Acknowledgeme f Receipt of Motorists <br /> Printed/Typed Name Signe re / d <br /> �. MonM'; pp;: Yin <br /> 19. Oiecrepency lndi alio Space / <br /> K <br /> t. <br /> It <br /> t- <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in nam 19. <br /> Printed/Typetl Name Signature Moftd)" YNf' <br /> 0 <br /> lzz A(I/aT) Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS INSTRUCTIONS ON THE ppilipJ[ <br /> UG—22 <br /> els) Previous editions are obsolete. To: P.O. Box 400, Socrofoento, CA 95802 <br /> e 1 + .iir=iAl <br />