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u .venareAgency <br /> P&m A Department of Health Services <br /> Approved OMB No.2QSl`0039(Expires 9-30-e r) Toxic Substances Control Division <br /> Pleeas print or type. (Form designed for use ane 'Pitch typewriter). � � Sacramento,California <br /> UNIFORM HAZARDOUS g i <br /> enerator'e US EPA ID No. Manliest 2. Page 1 Information In the shaded areae <br /> WASTE MANIFEST Do am m No. <br /> of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address I A. Slate Manifest Document Number <br /> .SIN PESTNA 9 TIP TUT <br /> 275 GRANT LINE FM TRACY "CA 953A B. State Generator's 1D <br /> 4. Generator'a Phone{ ) _ - L <br /> 5. Transporter t Company Name 9. US EPA !D Number C. State Transporter's ID <br /> 1 I7 <br />[ N C 0, Transporter's Phone <br /> i 7. Transporter 2 Company Mame 8. US EPA ID Number E. State Transporter':10 <br /> d�. F. Transporter's PhGMa <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number O. State Facifity's ID <br /> GSX SERYICLS OP-CALIFOMIA —"PWI <br /> LO F I H. Facility's Phone <br /> -o CA 93M 1C I A 1111 <br /> 1Z1 P. <br /> X12. Containers t .moo ar 14. I. <br /> .�"LL 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity UniE Waste No. <br /> No. Type Wtivol .+ ! <br /> a a. CALIMMIA REGUAT€D ' ' Stale <br /> 1rA5TC OtrLY I'C'I RCRII 0 0 I O T 0 0 0 Z 0 Y <br /> EPA/Other <br /> i�CY R b- Stale <br /> S A <br /> ab T <br /> v O EPAIOther <br /> "i 1 ' <br /> C11 r <br /> R <br /> Q c. <br /> 8 <br /> state <br /> 07 i; 1 <br /> EPA I Other <br /> w d. <br /> Z l State <br /> w 1 E <br /> v ' EPA r other <br /> ct� J. Additional Descriptions for Materials Listed Above <br /> X <br /> K. Handling Codes for Waste:Listed Above ' <br /> O _ <br /> SOIL Ct�AMINATEO WITH OIL & 6� � a e <br /> C. d. <br /> f- 15. Special Handling Instructions and Additional Information i,' k <br /> Lu 1RD11LL- # f 1 %2 3 ' <br /> �- kAR WKS, cc�s, & PmFCTIIIE mJm"F1'iT <br /> i3. <br /> ,,,p GENERATOR'S CERTIFICATION: I hereby declare thatlhe contents of this consignment 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 international and , <br /> national government regulations. � - <br /> I1 1 am a large quantity y perterfltor,i certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree i have determined r <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 and future threat to human health and the environment;OR,if I am a small quantity generator.I have made a good faith effort to minimize my weals <br /> generation and select the beat waste management method that is available tome and that I can afford. ! ; <br /> I <br /> Printed/Typed Name Signacuie Month Day Year <br /> 3 ' ! <br /> W R 17. Transporter 1 Acknowledgement of Receipt of Materials . T <br /> QA Printed/Typed Name Si nature <br /> N a Month Day Year <br /> LL S p <br /> O P ,. <br /> LU O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> sn <br /> Q R PrinfedrTyped Name ruisE :, Month Day Year <br /> 2 <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> 1 <br /> L I - <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materials coveted by this manifest except as noted in Item 19. <br /> y PrintedlTyped Name 'j Signatu.0 Month Day Year <br /> 11 <br /> DHS 8022 A(,188) 'Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. F f <br /> YELLOW: GENERATOR RETAINS <br />