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State of California—Health and Welfare Agency See Instructions on Back of Page 6 Deoartment of Health Services <br /> Form Approved OMB No.2050--0039(Expires 9-30-91) Toxic Substances Control Divis;on <br /> Please pant or type. Form designed for use an elite( h typewriter). and Front of PSC Sacramento,Ca,iforn n <br /> UNIFORM HAZARDOUS aerator's US EPA ID No. Meniteat . Page 1 information in the shaded areas <br /> Document No <br /> WASTE MANIFEST C A iC Q R 0 6 2 16 6 1 6 6 .315 40 <br /> of 1 s not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Docut <br /> �tIlLAGE i ST �f1,�tIryA 3v;t <br /> 66649 EIOARiCADERO DRI'r, STOCKTM, CA 952:09 B. State Generators ID <br /> 4. Generator's Phone(2M) fjSj_ CI ! <br /> 0 5. Transporter 1 Company Name 8. US EPA ID Number C. State Transporter's IDRC� 73V <br /> Lo <br /> RamN <br /> m «t 1 -r f D 0 4 Q Q 3 5 IS 6 D. Transporter's Phone g1 h-37 -2570 <br /> Irl 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> ao <br /> 0 1 1 1 1 1 1 1 1 1 1 1 1 F. Transporter's Phone <br /> CID <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> a RATIOS ENVNIT'VIE iTAL SERVICE <br /> u 1515 SOUTH RIVER ROAD, 141ES T SACftArIInT , CA 95691 R Facility s Phone <br /> 6z CA10741400135156 916-371-2570 <br /> 12. Containers 13. Total 14. 1. <br /> 11. US DOT Description(Including Proper Shipping Name.Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. I Type Wt/Vol <br /> (/�Y'� ,aril+ RCRA HAZAi;GOUS ',Jai T. LI`ZIlID Stated <br /> c_ ! <br /> M r N `^ j t J Q �� �7 EPA;Other 'r <br /> `^'� E b. V State <br /> C"N A <br /> 'i 1 <br /> A <br /> i T EPA/Other <br /> vl O <br /> 01 R C. State <br /> o I <br /> 0 <br /> M <br /> A! her { <br /> ¢I <br /> w d. State ! <br /> Z <br /> LU <br /> ,J EPA/Other <br /> wl <br /> Z J. Additional Descriptions for Matenals Listed Above K. Handling Codes for Wastes Listed Above <br /> O f !� ��d.jAill`r'J p-7—C- a. b. <br /> CL <br /> rn <br /> U, <br /> ¢ <br /> C. d. <br /> al <br /> r 15. Special Handling Instructions and Additional Information <br /> Z USE APPROPRIATE PROTECTIVE GEAR, USE STAMARD SAFME PRECAUTIONS. <br /> w <br /> LE"1ERGE.W-Y CONTACT n 916-371-2570, 300-477-72 19,15. <br /> J <br /> J <br /> V I 18. <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,pecked,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> CL national government regulations. <br /> U) <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 to the degree I have determined <br /> O 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 /> 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 /> } generation and select the best waste management method that is available to me and that I can afford. <br /> 0 <br /> Z <br /> LU Printed/Typed Name Signn re / Month Day Year i <br /> Lu <br /> W T 1 Transporter 1 Acknowle gement of Receipt of Materials <br /> R <br /> Z A Prir�iedy yped Name urs <br /> N / Monro Day Year <br /> LL <br /> O p <br /> w O 18. Transporter 2 Acknowledgement of Receipt of Materials 1 <br /> G R Printed/Typed Name Signature Month Day Year <br /> c) E <br /> Z <br /> 19. Discrepancy Indication 6pace i <br /> F <br /> C I <br /> L <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 <br /> y Printed/Typed Name Signature Month Day Year <br /> DHS 8022 A Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.8-89)Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (.�{,r3Z. �J To: P.O. Box 400, Sxramento, CA 95812-0400/ <br />