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Slate of Call fornla—Health and Welfare Agent Department of Health Services <br /> Toxic Substances Control Division <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) Sacramento,California <br /> UNIFORM HAZARDOUS ^1.Gpn to'su5 AIDNo. r Mantled z. Page 1 Information In the shaded areas <br /> WASTE MANIFEST 1 i � � _ o`ument No/ or ( Is not required by Federal <br /> 3�en�r�toY��ame n cMr-al I Address a Al- <br /> 5. <br /> �Jtg I A.Stt$Ito((����..�11(§g([[����Iryyst o urr��err��Number <br /> CA it <br /> � s� CUC %IIi�07 e.state GeneratoN�1r�s-��lD`77 <br /> 4. enerator'e one( (l ) 7 /�_J. ST At �- /L Trans / TC.State Transporter'a I� umbb <br /> 7/! ) VGpt7r 0l. <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E.State Transporter's I <br /> F.Transporter's Phone <br /> 9Dealpnatepp III ams and Site Address 10. US EPA ID Number G.State Facility's ID <br /> ��U �K �ZtYCcf 4AM �1 <br /> Cl Sr1Y0.) r Phone P <br /> Q! <br /> } C <br /> 12.Contain ' 13. 14. <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total Unit <br /> ' No. Type Quantity WWoi Waste No. <br /> lC4rcL7eS ,��); P)X,.os_ k'/�1 � 33! I�� <br /> E d� �i��+Sr�� D� lDn3� C� lv" <br /> R <br /> T <br /> FIM 5i �j CI t) s t1c <br />.(.1J J. Addll anal De r1l tion or Metenals Listed Above IL Handling Codes for Wastes Elated Above <br /> Q . rtral7 1 Crt ez f �- <br /> b• c �D S Qd <br /> q- <br /> Cn a <br />-00 Wr I '0-� <br /> ZD 15.S cisl Handling Instruction and Addl o al Information <br /> M � <br />)o J 11 <br /> 16"GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately descrlpped above by <br /> proper shipping name and are classified,packed,marked,and labeled,and are In all respects In proper condition for Transport by highway <br /> according to applicable International and national government regulations. 1 <br /> Unless I em a small quantity generator who has been exempted by statute or regulation from the d y to make a waste minimization certification <br /> under Section 3002(b) of RCRA, I also certify that) have a program n p ac -red a volume d toxicity,''of waste generated to the degree I <br /> have determined to economically pretlticabla and I have selected the math tigatmenl, a e, or disposal currently available to me which <br /> minimizes the resept and future threat t human health and the environment. / _ <br /> Ih Me )ed em Ent <br /> Signature Month Da y Yea <br /> T 17.Transporter 1'Ac n wledgem n✓of Receipt of Materials - --� <br /> R <br /> R PrintetlRypetl Name S net a J Month Day Year <br /> a <br /> P K F/ 7 <br /> 0 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> T Printed/Typed Name Siazure <br /> E Month Day Year <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I <br /> 20.Facility Owner or Operator. Certification or receipt o1 hazardous materials covered by this manifest except as noted In Item 19. <br /> Printed/Typed Name Signature Month Day Year <br /> DHS 8022 A(11185) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (EPA 8700-22) To: P.O. Boz 3000, Sacramento CA 95812 <br />