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anuvrsnareAgency Department of Health Services <br /> Fbrm Approved OMB No.2060--0039(Expires 9-30-^" Toxic Substances Control Division <br /> Please print or type. (Parol designed for use on e! :pitch typewriter). L Sacramento,California <br /> i <br /> UNIFORM HAZARDOUS 'enerstors US EPA ID No, Manires! 2. Page 1 information in tha shaded areas <br />{ <br /> WASTE MANIFEST Do omen No. <br /> If <br /> Page <br /> is not required by Federal law. <br /> 3. Generator's Name and Malting Address i A. State Manifest Document Number <br /> IM F�E�Sp,�TrAM OTIP TRUST '' =° <br /> 275 Gl�I'1t�1 BE R TRACY Ci .r✓I 95B. State Generator's ID <br /> d. Generator's Phone( ) v t w376 t7 - — v <br /> O 5, Transpo�rterr'11 Company Name 8. US EPA ID Number C. State Transporter's ID <br /> N <br /> PA�IU TRWf �� O 15 $ O D. Transporter's Phone _ <br /> 7. Transporter 2 Company Name a. US EPA tD Number E. Slate Transporter's ID p <br /> F. Transporter's Phone 1 <br /> 9. Designated Facility Name and Site Address 10. US EPA ID N11 umber G. State Facility's ID .r <br /> � <br /> 6� ,&}Y, SERVICES�FM <br /> OF LALIFO'NIA L nil <br /> .V L01E I f�.�'11J I H. Fa if t P <br /> L 'i t ,il LLl�ri CA A D i U r -�►1 <br /> '3 12. Containers 13. Total 1a. I. <br /> .Y�� 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID'!Number) Quantity Unit Waste No. j <br /> i No. Type Wt1Vol <br /> +`w °' State <br /> CALLIFORdA REG ATE) WASTE LILY fMi Rd" 0 0 1 D T O 0 020 Y EPA/Other <br /> G <br /> ^� N r <br /> E b. <br /> R State <br /> A <br /> T <br /> EPAtOlher <br /> 0 I <br /> N <br /> R C. <br /> stets <br /> EPA/Other <br /> LU d' Slale <br /> W ;f <br /> U I ilEPA 1Other <br /> Lu <br /> co J. Additional Descriptions for Materials Listed Above S K. Handling Codes for Wastes Listed Above <br /> SOIL COWAMINATED WITH OIL g GWAW s a. <br /> a C. d. i <br /> J a <br /> a <br /> 2 i- t <br /> -'i <br /> 15. Special Handling Instructions and Additional Information <br /> Z 1[`F WI i If # t}�1 <br /> GMI-S, PMEG 1VE E'9JI FTV T <br /> I <br /> a <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by properl�shlpping 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 /> r4 national government fegulallons. G ',I r <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 available to me which minimizes the <br /> present end future threat to human health and the environment;OR,if I am alsmatl quantity generator,I have made a good faith effort to minimize my waste I <br /> generation and select the best waste management method that is available 10 me and that I can afford <br /> LU i <br /> PrinledrTyped Name Signature !Month Day Year <br /> I <br /> WR 17. Transporter f Acknowledgement of Receipt of Materials, <br /> Z A Printed/Typed Name <br /> ¢ N Signature Month Day Year <br /> 0 p l , <br /> LW O 18, Transporter 2 Acknowledgement of Receipt of Materiels, '§ <br /> t R PrintelrTyped Name <br /> U 1 Signature r _I Month Day Year <br /> z E - � !'I t r . �r F f F j � <br /> 1 / <br /> 19. Discrepancy Indication Space , <br /> F <br /> A <br /> C <br /> I <br /> L ii + <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covared by this manifest except as noted in Item 19. <br /> T <br /> y r�� <br /> ped Name <br /> Signature Month Day Year <br /> c <br /> 1 <br /> l <br /> DHS8022 700-22 A 2 yes) <br /> EPA 8700 Do Not Write Below This Line <br /> EPA <br /> t (Rev.9-88)Previous editions are obsolete. <br /> ry + YELLOW: GENERATOR RETAINS <br />