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aia:eouronwa—Healthand Welfare Agency ' Department of Health Services <br /> Form Approved OMB No.2050--0039(Expires 8-30' Toxic Substances Control Division <br /> PIOaserint or 1 <br /> P ype. (Form designed for tree ane ,;-pitch typewriter). � � Sacramento,California <br /> t UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest 2. Pace t Information in the shaded areas <br /> WASTE MANIFEST I Document No. <br /> f. <br /> 3121 Ci 1,11 of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address = A. Skate Manliest Document Number <br /> TRUST �. � r: � - ! �Pj�JiPAfjAt1ArQTIP :..E ROAi3 TRACY� t �.I 9 537b B. State Generator's 10 <br /> 4. Generator's Phone( } <br /> 14 Al H1 01 4161 . <br /> 5. Transporter T Company Name e. USI EPA ID Number C. State Transporter's ID 4 21j <br /> PAUU� T �� <br /> ,y � (` D. Traneportar's Phone � <br /> 7. Tren_sporter 2 Company Name <br /> B. US!EPA ID Number E. State Tranaporter's ID . -".a.! <br /> All. 1 s. , t,.. �i. I,. f ! F. Transporter's Phone <br /> 9- Designated Facility Name and Site Address ,' 10. US?EPA ID Number G. Slate Facility's ID <br /> t����1('C��St3�t,' CYIC-ES OF CAuFnIIA #-- FIJI <br /> H. Facility's Phone <br /> J4, CA 932M ICIAID191 <br /> 2. Containers T a T4. L <br /> 7,. US DOT Description(Including Proper Shipping Name.Hazard Class,and ID�Number)" Quantity Unit Waste No. <br /> No. Type Wtivol <br /> State j <br /> E CALIMMIA REGL,1..ATF.O 'tE "alLY tj(pi RCyR4 0 0 0 T 0 0 0 i 0 Y r <br /> N <br /> E b. <br /> R + Slate <br /> A <br /> T # <br /> v O I <br /> EPA!Other <br /> CA R C. <br /> State <br /> EPA/Other i <br /> w d, <br /> Z State <br /> cw7 til EPA/Other <br /> ZJ. Additional Descriptions for Materials Listed Above I K. Handling Codes for Wastes Listed Above <br /> SUIL COKAMINATED WITH OIL a GWASE 1 <br /> ,i <br /> C. <br /> d <br /> J <br /> 1f <br /> 15. Special Handling Instructions and Additional Information' <br /> ',AAR Uff&S, G4WLES, S PRD"ECTM EQUI I'T <br /> a ,8. <br /> ' 1 <br /> J GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and are classified,peeked,marked.and labeled,and are in all respects in proper condition for transport by highway according to applicable international and I <br /> h national government regulations. ' <br /> it I am a large quantity generator,I certify chat I have a'progrem in place to reduce the volume and toxicity of waste generated to the degreel have determined , <br /> to be economically practicable and that I have selected the practicable metKod 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 f am&'small quantity generator,I have made a good faith effort to minimize my waste <br /> generation and select the best waste management method that is available to me and that I can afford. <br /> Printed/Typed Name Sign lure :Month Day Year i <br /> W R 17. Transporter t Acknowledgement of Receipt of Materials . <br /> Z¢ A Printed r Typed Name Signature month Day ay Year <br /> 1L cS <br /> O P s <br /> W O 18- Transporter 2 Acknowledgement of Receipt of Materials p i <br /> rA R <br /> UT PrintedlTyped Name Signature 'Month Day Year <br /> {! <br /> 19. Discrepancy Indication Space <br /> i <br /> F i <br /> A 1 <br /> C t i <br /> L ! <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 Day Year 11 <br /> n <br /> Il <br /> DHS 8022 A(I/88) Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. <br /> YELLOW: GENERATOR RETAINS <br /> t <br /> t. <br />