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stareop%,amorma�eenga yreflareAgency See Instructions on BP^k of Page 6 Departmentofmeaunservices <br /> Fa?m Approved OMB No. 39(Expires 9.30-P" Toxic Substances Control Divisior <br /> and Front of ' � 7Please rint or type. Fararned fpr use an e!N ifc�r typewriter), <br /> f Sacramento,California <br /> UNIFORM HAZARDOUS enerator's US EPA ID No. l Document No.Manifest 2. Page 1 Information In the s <br /> Doccumenhaded areas <br /> f l I} i e} t i t f l I I I I I of I is not required by Federal law. <br /> WASTE MANIFEST r, I' 11 <br /> 3. Generator's Name and Meiling Address .i A. Stale Manifest Documre�nt Number <br /> r B. state 0"Orator's ID <br /> 4. Generator's Phone(i '.'I s")I :S " "' 4 I <br /> I ill <br /> 5. Transporter 1 Company Name 8. US EPA ID Number C. State Tranaporter'a IDLn <br /> 1 111 "1 S ,� rat:1l1 v Iii 1; I I int a r ( r D. Transpoder's Phone l <br /> N ' i <br /> m 7. Transporter 2 Company Name e. US EPA ID Number E. Slate Transporter's ID , <br /> oF. Transpoft4Ws Phone F <br /> m 9. Designated Facility Name and Site Address 101 US EPA ID Number G. Slate Facility's ID <br /> I` i <br /> ;!pf `,.'1, :^ i', mf,ar:� I' R 111.1 it 11114 <br /> U I:1 rt? lac;r 1 it "t t r:nt H, Feclllfy'aPhorte <br /> .,Q , , Ft .-}rs; i.:r ',"� 'ti!1 ; :� )� tt i! ) ! I + .', t�I!� 1 `?Q.s...4�► i'1 Ii <br /> Z <br /> O 12. Containers 13. Total 14, 1 1. <br /> 11, US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> I 3 No. Type Wt/Vol <br /> a a. State i ,r <br /> U I <br /> Z G r. t'I} ,r: 1'.."1'Y I.ItNFfT1 ilii <br /> :1 '1`11 F fin ) i <br /> E EPA10ther <br /> N I' I I '1' d <br /> E b. <br /> State <br /> H <br /> N R f <br /> o q 4 k , <br /> m T p EPA10ther <br /> a O € <br /> N <br /> C. <br /> v I (State , <br /> 0 LL l I I I I <br /> Ot <br /> EP / her <br /> LU d. LEPA10thm- <br /> LU <br /> te I <br /> Z <br /> it <br /> U t i P 1 <br /> U) J. Additional Descriptions for Materiels Listed Above <br /> z K. Handling Codes for Wastes LEated Above <br /> a YltKI. A1, :.1iE', ki1'i'P,N a. I.! b. , <br /> Cr .. e. d. <br /> ?s <br /> 4 i <br /> Z <br /> o <br /> F- 15. Special Handling Instructions and Additional Information <br /> Z <br /> S <br /> � @ I <br /> , l, I `. 1'1: r3't�'iE<I"i'i',r:; I'i.'i'r•I111; ; �rlis ir:'r•i€ :'rF;r. <br /> C¢J <br /> I& I <br /> I'. <br /> GENERATOR'S CERTIFICATION: I hereby declare khat the contents of thislconsignment are fully 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 int <br /> n f <br /> arnational and <br /> national government regulations. .,co ,,k <br /> cc if I am a large Quantity generator,f 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 to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the j <br /> present and future threat to human health and the environment;OR,If I am ajamall quantity generator,I have made a good faith effort to minimize my waste <br /> U generation and select the beat waste management method that Is available <br /> to me and that I can afford f E <br /> Z <br /> Lu Printed/Typed Name Signature <br /> �y Month Day Year <br /> IlJ <br /> wAT 17. Transporter 1 Acknowledgement of Receipt of Materials t { <br /> Q A Printed/Typed Name Sign ti)ra / Month Day Year <br /> O P 1i �z✓...� trL.� f SEW �_.t••Ar <br /> Are- <br /> LU O 18. Transporter 2 Acknowledgement of Receipt of Materials'' <br /> t LR Printed/Typed Name Signature Month Day Year <br /> � <br /> Z R k <br /> ! <br /> 19. Discrepancy indication Space <br /> F <br /> C I <br /> L J <br /> t 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 Oay Year <br /> DHS 8022 A - Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.8-89)Previous editions are obsolete. <br /> YELLOW; GENERATOR RETAINS <br />