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<br />Department of mano oa..
<br />.. -- Toxic Substances Control Divi
<br />te�rr,ryry / Seeramento, CeIBr
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<br />DHS 8022 A 0/ 87) YeRo,w TSDF SENDS THIS COPY TO MNERATOR WITHIN 30 DAYS_
<br />EPA 87022
<br />(Rev. 8-86), Previous editions are obsolete.
<br />lyi"AZ4000US Document No. ':, p1 I j is gf)t required by Federal ew.
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<br />6. - US EPA ID Number
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<br />S. Transporter t Company Name
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<br />US EPA 10C Number
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<br />7. Transporter 2 .,any Neme e.
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<br />9. Daeipnelad Facility Name end Sita Addreae 10.. US EPA )D Number
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<br />12. Containers 13. Total 14.
<br />11, US DOT Description (Including Proper Shipping Name. Hazard Class, and ID Number)
<br />Quantity Unl! Wase Nri
<br />No. Type
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<br />J. Adddlo al Desc,,Rtions for Materials Listed Above
<br />K. Handling Codes for Wastes Listed Above
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<br />15. Special Handing las1nrctlons and Additional Information
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<br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping �
<br />for transport by highway according to applicable
<br />- name and are classified, packed, marked, and labeled,. and are in all respects in proper
<br />condition
<br />international and national government regulations.
<br />I certify that I have a program in place to reduce the
<br />-
<br />volume and toxicity of waste generated to the degree 1 have
<br />ifI am a large quantity generator,
<br />__ cletemdnedto-be. economically practicable and that 1 have selected the practicable method of treatment, storage, or disposal currently available to
<br />OR, if I a small generator, -f Piavemade a good
<br />me which minimizes the present and future threat to human health.and the environment: am quantity
<br />method that is available: to me and that 1 can afford.
<br />faith effort to minimize my waste generation and select the best waste management
<br />Printetl/Typed Name - Signature
<br />- - Month Day Year.
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<br />17. Transporter 1 Acknowledgement of Receipt of Materials
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<br />Pretrad YTyped Name Signa e
<br />Month Day Year
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<br />18. Transporter Acknowledgement of Receipt of Materials
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<br />Print aD: Typed Name
<br />Signature
<br />.. Month Dey Yeer
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<br />1 . Discrepancy Indication Space
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<br />20. Facility Owner or Operator Ce cation of r9piript of hazardo s materials covered by this manifest except as noted in em 18. '\
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<br />Printed/Typrid mN Signilt,"a -
<br />1. Month D Yeer-. ,
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<br />DHS 8022 A 0/ 87) YeRo,w TSDF SENDS THIS COPY TO MNERATOR WITHIN 30 DAYS_
<br />EPA 87022
<br />(Rev. 8-86), Previous editions are obsolete.
<br />
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