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State of Callfomis—Health and Welfare Agency De0artment of Health Services <br /> Form Approved OMB No.2060-0039(Expires 9.30-91) , Toxic Substances Control Division <br /> Please print or type. (Form designed for use on Pate I, typewriter). Sacramento,California <br /> UNIFORM HAZARDOUS 1. enarator'a US EPA ID No. Manifest Paget Information in the shaded areas <br /> WASTE MANIFEST is / a ogpm�nt No..- - <br /> "+ of is not required by Federal law.,,., ' <br /> 3. Generator's Name and Mailing Addresq A. State Manifest Document Number <br /> 4. <br /> 886-51277 <br /> 8. State Generator' O - <br /> 4. Generar's Phone(-�x <br /> to <br /> 6. Transporter 1 Company Name 8. US EPA ID Number C. State Transporter's IDto <br /> .+ <br /> Ce 1 D. Transporter's Phone <br /> 7. Transporter 2 Company Name S. US EPA 10 Number E. State Transporter's ID <br /> CP <br /> gF. Transporter's Phone - <br /> 9. Designated Facility Name and Site Addnlas lo. US EPA ID Number G. State Facility's ID - <br /> < Wineries S trylce H. Facility's Phone <br /> 23331 He 1111117, 33 - <br /> ' ' 12. Containers 9l31"; 14. L <br /> 11. US OOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt/Vol <br /> Lai <br /> a. t t State <br /> t 141 1 TT G <br />_ G <br /> l EPA/Other <br /> �; E b. Stat <br /> WN R <br /> TEPA/Other . <br /> N 0 <br /> a R c. State <br /> , g <br /> m <br /> EPA/Other <br /> Fd• State <br /> Z <br /> tW,) EPA/Other <br /> LU <br /> Z J. Additional Descriptions for Materials Listed Above K. Handlhtg Codes for Wastes Listed Above <br /> .-.., a. It. <br /> a. i, <br /> Uj <br /> c. d. - <br /> J <br /> Z <br /> 0 <br /> 16. Special Handling Instructions and Add'tonal Information <br /> _ IL �.i. t... 4. f' �- /i T _) . ._ �.- ( '� f 1 _,: :j '':. 7 ti:.L�t.�.� L rt {'. 1 + i <br /> J <br /> J <br /> Q 18. <br /> • V , <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J 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 /> Nnational government regulations. <br /> If I am a large quantity generator,I c:rtify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> p to be economically practicable and`:rat 1 have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes 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 /> j generation and select the beat wastr,management method that is available to me and that I can afford. <br /> Z <br /> CW9 Printed/Typed Name -7Signalure Month Day Year <br /> Lu T 17. Transporter t Acknowledgement of Receipt of Materials <br /> R <br /> < N/ ped Name �.�) Month Day Rear <br /> pP k.+e ! 4� t �...a /• t •_ail L't. �,r,,, / 411 % /1 <br /> W O ransporter 2 Acknowledgement of Receipt of Materials <br /> ` V T Printed/Typed Name Signature Month Day Year <br /> E <br /> 2 <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> Q <br /> I <br /> �. L <br /> 1 <br /> T 20. Facility Owner or Operator Certificat,fn of receipt of hazardous materials covered by this manifest except as noted in hem 19. <br /> y Printed/Typed Name Signature Month Day Year <br /> DHS 8022 A(1188) Do Not Write Below This Line <br /> EPA 8700=22 <br /> (Rev.9-88)Previous editions are obsolete. <br /> YELLOW: GENERATOR RETAINS <br />