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Approved OIAB No.2030--0039(Expires 930.9 Toxic Substances Control Division <br /> Please print or type. (Form designed for use on alit Etch typewriter). Sacramento.California <br /> UNORM HAZARDOUS Generator's US EPA ID No. Manil'at ?,Page 1 Information in the shaded areas <br /> WASTE MANIFEST of is not required by Federal law. <br /> 3. t- 1"A WVLi`I/� 1� SJC o C, A. State Manit4ratQogu 9 Number 0 3 3 <br /> �70 0 ir � ( � 7 -- T' B. State Generator's ID <br /> 4. Generator's Phone 0 O <br /> ran erName 8. US EPA 10 Number C. State Transporter's 10 <br /> Cfa MCA <br /> It- D. Trane <br /> N \A� porter's P tai <br /> 7. Transporter 2 Company Name 8. US EPA ID Numb r E. State Transponer's <br /> F. Transporter's Phone <br /> m <br /> 9. Oesigasted Facility Name and Site Address 10. US EPA 10 Number a State Facility's ID <br /> &iCkSOn, Im. <br /> 0 255 Parr Blvd. H. Facility's Phone <br /> M:5 Ridywall, Ca. 94801 (415) 235-1393 <br /> MZ <br /> D 012. Containers 13. Total 14. L <br /> a 11. US OOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Ouantity Unit Waste No. <br /> cm No. Type Wt/Vol <br /> Cn U s Wasre State <br /> 00 2 <br /> C N Rwmt xm Waste Solid. P EPA/Otho <br /> Go�r.yy��3 <br /> N R b State <br /> o <br /> � T EPA!other <br /> NO ...."",��. <br /> f R c, �� State <br /> EPA <br /> /Other <br /> w d. <br /> F State <br /> Z, <br /> W <br /> U EPA/Other <br /> W <br /> N J. Additional Descriptions for Materiels Listed Above K. Handling Codes for Wastes Listed Above <br /> r Qty.-.-2— EamPty Storage Tank (s) 00 OG) a. b. <br /> M , . Tank (e) have been��35"lbs. <br /> c. d. <br /> Dryice P== 000 Gal. Capacity. <br /> z <br /> 0 <br /> 15. Special Handling Instructions and Additional Information <br /> W achy fmn sources of ignition. Always wear 's> its"when workroing aala <br /> U.S.T.Is <br /> J <br /> J ' <br /> V t8. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are tufty and accurately described above by proper shipping name <br /> 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 /> N national government regulations. <br /> If 1 am a large quantity generator.1 certity that I have a program in place to reduce the volume and toxicity of waste generated to the degree 1 have determined <br /> 0 to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimize*the <br /> >- present and future threat to human health and the environment;OR,If I am a small quantity generator,1 have made a good faith effort to minimize my waste <br /> WZ I generation and select the beat waste management method that is available to me and that 1 can afford. <br /> p <br /> Printed/Typed Name Sign t e Month Day Year <br /> W <br /> W R 17. Transporter t Acknowledgement of Receipt of Materials <br /> QA Printed/Typed Name nature <br /> N Month Day Year <br /> O S NO) v k�\QS <br /> P 18. Transporter 2 cknowledgemem of Receipt of Materials <br /> W O <br /> UT Printed/Typed Name nature Month Day Year <br /> E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I 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(,188) Do Not Write Below This Line <br /> EPA 8700--22 <br /> (Rev 9-88)Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> To: P.O. Box 400, Sacramento, CA 45812-0400 <br />