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b <br />_g <br /> Slate of Ca dorm.—Health and Welfare Agency Departmam of Health Sam <br /> Form Approved OMB No.2050-^DO:f9{Expuse 2-30-9 1) TaA,c Suaatenen Control 13— <br /> Plea— <br /> hrPleaae print or lyra. (Form designed for use on ahfe 02-illi rlyewnfer). Sacramento,Calif <br /> ® � UNIFORM HAZARDOUS t.Oanera[or'a US EPA ID No. Mandeal 2.Pegs 1 <br /> Document No. information in IM anaded ossa <br /> E WASTE MANIFEST ' ti r, 1 r i / at is not requtrad by Federal law- <br /> 3. Generalor's Name and Mailing Address A.Slate Man s u12i 1LN0 e„ <br /> 1.-�•.t .i I S.Stale Ganerslors ID <br /> f <br /> 4.Can eraler's Phone(' ) '' .r r' ►r r .% V C1 7 'f ! <br /> 5.Transporter 1 Company Name e, US EPA ID Number C.Snb 7ransparter'a 10 - f i f w <br /> •r k 'r• ''� i ,. D.Tranaportaes Phare- A. .r a♦,- <br /> h <br /> 0 7.Transporter 2 Company Name 8. US EPA 10NumberE.Slats iranaportMa ID <br /> 1 $ F.Tranaportu'a Ptla+e <br /> cL 9.Designated Facility Name and Site Address 10. US EPA TO Number G. State Facility's 0 <br /> pit U r, .�•:Ly,. •� •• f H. F_a/ci ity's Phone - <br /> y <br /> i) q J •12.Conleinars 13.Tota] 14, i. <br /> 00 11.US DOT Description(including Proper Shipping Nam,Hazard Class,and 10 Number) Quantity Unit Waste No. <br /> No. Type W1 Vol <br /> Stale <br /> � °' _' • _ }.. � ' (:r= 'lug..;rr.}�: L �,",' ..->2.3 <br /> 't', G f ��Ud EPA101her <br /> N <br /> E b. Slots - <br /> [V R <br /> A EPAl Other <br /> o� T <br /> c <br /> Slate <br /> a , <br /> g EPAr Other <br /> • � d SSala <br /> tzu EPA/other <br /> U <br /> m J.Additional Deaqripllwa for Materials Listed Above IC.Handling Codes for Waetee Listed Above <br /> r zel C. d. <br /> 6 <br /> 1 O <br /> 15.Special Handling Instructions and Addifionel IntWmation <br /> 4 <br /> Z <br /> zu <br /> 1 N <br /> r U 18. <br /> GENERATOR'S CERTIFICATION: I hereby dadare that the Contents of this consignment are fully and accurately described above by proper shipping name <br /> I and are classified,packed.mat(ad,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> 0. national govemment regulaliOna. <br /> V) <br /> 111 am a large quantity generator.I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> O io be economically practicable and that I have selected the practicable method of treatment,storage.of disposal currently available to me which minimizes the <br /> Y present and future threat to human health and the anYuonment:OR.If I am a small quantllY generator.I have made a good faith effort to minimize my waste <br /> es) U generation and select the beat waste manmethod ethod that Is available to me and that 1 can allord. <br /> r w Printed/Typed Name Sigaa''afe Month Bay Year <br /> cc 41F -j <br /> k V.Transporter 1 Acknowledgement 01 Receipt of Materials <br /> w R <br /> =a A Printed/Typed Nome Signature Month Day Year <br /> [ u_ 5 Y.•'!1 ..:, r1rr r"r��,:� ri t,ai..,+. ..t,l� a ,! <br /> f O p <br /> 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> UR PrintadrTyme ped Na ; Signature luroalh Day Year <br /> E <br /> Z_ R <br /> 19.Discrepancy lsdicalton Space <br /> F <br /> A <br /> C <br /> ' 1 20. Facility Owner or Operator Certification at receipt of hazardous materials covered by this manifest except as noted in Liam 19. <br /> ' T Signaturo Month Day. Year <br /> y Pfulledr Typed Name - - <br /> DHS b022 A(1168) Do Not Writs Below This lint <br /> EPA 11100-22 - - - <br /> � <br /> (Rev.(r88)Previous edllialla are obsolete- <br /> � YELLOW: GENERATOR RETAINS <br /> "s-- 1 , 1`V � of •l�l�a7� <br />