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f+brm A w a""enocrauereAgency ;; Department of Health Services <br /> ppreved OMB ko.2060--Up39(Expires 9-3[1^� Toxic Substances Control Division <br /> Pleaaerint or type.ype. (Form designed for use on e. � �Vitch typewriter). � Sacramento,California <br /> UNIFORM HAZARDOUS Generators US EPA tD No. s, Manifest 2. Page f k <br /> WASTE MANIFEST iR o m t Information in the shaded areas <br /> A 2191of is not required by Federal law. <br /> 3. denerafor'a Name end MsBing Address 'i A. Siete Manifest Document Number <br /> I� PUT" QTIP T ^ �" ��'n <br /> 7�' /� r �yI�#� RUST - { � <br /> 2 � C-Rm LRE MAD T�Y 95.-)76 8. State Generator's ID I. <br /> S. Generator's Phone( ) <br /> .9 <br /> 6. Transporter 1 Company Name 8. us EPA to Number C. State Transporter's ID <br /> A ' <br /> NAudLTRUING r D. Transporter <br /> 'a Phone <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. Stets Transporter's Ip. <br /> F. Transporter's Phone 1* <br /> 1-r _ <br /> 9- Designated Facility Name and Site Address 10. U5 EPA to Number G. Stele Facility's ID <br /> '1ZWICU OF CkIAl <br /> FM41A 4 <br /> H. Facility's Phone <br /> Cl At Di 9LO, 01 75Z7 SX-M-M <br /> 12. ConteInera t3. Total 14. ), <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and to Number) Ouantity Unit Waite No. <br /> .-.t a No. Type Wt!Val :,' <br /> (S Slate <br /> .c G G I.IIA REGULATED WASTE ONLY €0"i XPA 0 � L' T 0 0 0 � Y <br /> E <br /> * N , <br /> :[ s E b. + <br /> R State r <br /> A <br />! �' EPA/Other <br /> Y v R <br /> State <br /> aj b f <br /> EI PA!Other <br /> w d, <br /> F <br /> Z state <br /> Lu r <br /> j' i <br /> LEPA/Other <br /> J. Additional Descriptions for Materials Listed Above ! <br /> x K. Handling Codes for Wastes Listed Above <br /> hb. <br /> SUIL C4NTAMINAI D WITH OIL &0EASE <br /> C. d. I <br /> a <br /> H 15. Special Hait <br /> ;Xjndling Instructions and Additional Information ' <br /> i <br /> AIM (IOW-S, GUGGLES, $ PMECT I VE EIJJI F ST <br /> 'EI; <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> end are classified,packed,marked,and labeled,and are in all respects in prepar condition for transport by highway according to applicable international and <br /> national government regulations. <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 /> to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently availableto me which minimizes the <br /> } present and future threat to human health and the environment;OR,It I em a small quantity generator,I have made a good faith eflort to minimize my waste <br /> generation and select the beat waste management method that is available tome and that I can afford. <br /> Printed/Typed Name Ij Signature--" - Month Day Year <br /> I� I <br /> W R 17. Transporter 1 Acknowledgement of Receipt of Materials ,. <br /> 2I <br /> A PrintedlTyped Name <br /> C N Signatue Month Day Year <br /> LL s <br /> O P <br /> L" 0 18. Transporter 2 Acknowledgement of Receipt of Materials ti k <br /> PE PrintedlTyped Name Slgnatues - Month Day Year <br /> 19. Discrepancy Indication Space li _ ' I ; <br /> F <br /> A <br /> C <br /> L I i <br /> T20, Facility Owner or Operator Certification of receipt of hazardous materiels coveted by this manifest except as noted in Item 19. <br /> p <br /> y Printed/Typed Nameignature Month Day Year <br /> 778- <br /> 4 <br /> DHS 8022 A(1/88) Do Not Write Below This Line <br /> EPA 6700-22 <br /> 1 (Rev.9-88)Previous editions are obsolete. if <br /> YELLOW: GENERATOR RETAINS <br /> i . <br />