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^vr �.rovmrsno.20800039(Expires 9.30-9 t) Department of Health Services <br /> Please print or type. (Form designed for use on ell -pitch typewriter). Toxic Substanees Control Division <br /> UNIFORM HAZARDOUS Manifest 2 Paget Sacramento,California <br /> Generator's US EPA!D Nc. § <br /> WASTE MANIFEST C O 0 U 1 r�4L9 1J°t°rnol Information in the shaded areae <br /> 3. Generator's Name and Mailing Address of � is not required by Federal law. <br /> A. <br /> Stale Manifest i411`4 F st Documen Number <br /> Do <br /> 5 GMNT <br /> AE <br /> gr <br /> ! <br /> LI '! '""'�' 7r7"rr f3. State paneratvr'e IQ <br /> 4. Generator's Phone( ) E <br /> I 4 <br /> 5. Transporter 1 Company Name <br /> +n � � T I <br /> W) 8. US EPA ID Number C. State Trartaporter'e ID <br /> xp <br /> a D. Trane orter'e Phone <br /> 7. Trdnsporter 2 Company Name - <br /> 8 t 8- $ 05 5760 US EPA fb Number E. Slate Transporter.ID 1 ! / <br /> �- F, Transporter's Phone <br /> 9. Designated Facility Name and Site Address ` ' f <br /> GSX SERVICES � GILIFORUTA F'I US EPA ID Number G. sl#te Feeilfty'a iQ <br /> 3 <br /> -49 <br /> 3 1 <br /> b �WM. CA 9.06 ! G 0 9 8 o 6 7 5 2 7 0 H. F� i --7341 <br /> i t. US DOT Description(Including Proper Shipping p 12. Containers 13. Total 14 <br /> LL P pp g Name,Hazard Class,and ID Number) f. <br /> OuanTily .Unit Waste No. <br /> (;U a. h No. Type Wtivol <br /> -j r CALIFi`MNIA KGUTF.D MSSTE (AtY r1 i RCRA 00 1 0 7 U D o 2 Y State <br /> I <br /> N r <br /> E b. I <br /> R <br /> A i; s State <br /> T <br /> Rc EPArOther <br /> Stets <br /> d it I EPA/Other <br /> W d. <br /> s– <br /> WZ State <br /> w ! f° EPA101her <br /> Z J. Additional Qesoripttotts fa Materials Listed Above G <br /> p i K. Handling Code.for Wastes Listed Above . <br /> y SOIL Ct NWED WITH OIL a'GWASE a. <br /> b <br /> a 4 C. d. <br /> o <br /> Q 15, Special Handling Instructions and Additional Information <br /> z <br /> PlUILE # M — 552 9 <br /> ik:AR mss. GMES. 9 PROTECTIVE BAJI�T s�T <br /> L <br /> U <br /> - h i <br /> GENERATOR'S CERTIFICATION: I hereby declare th#1The contents of this consignment are fully and accurately described above by proper shipping name <br /> and are classified,pecked,marked,and labeled,and are in all respects in proper condition for transport by highway according!a appli <br /> national government regulations. cable international and <br /> rr N i am a large quantity generator,I certifythat I have a �� + ' <br /> �j to be economically practicable and that have selectedthepracticable meth d o!Ire atment,storageume and .ortdispo diY at sposal currently available to me whiced to the degree I h minim ies'the <br /> present and future threat to human health and the environment;OR,it I am a small uant!1 <br /> } q t Generator,i have made a good faith effort to minimize my wsale <br /> U generation and select the best waste management method that Is available to me and that i cart afford. ,h <br /> ` i I <br /> Printed/Typed Name Signature ! <br /> ~! Month Day Year <br /> w R 17. Transporter 1 Acknowledgement of Receipt of Materials i. <br /> Q A Printed/Typed Name <br /> 5 ��. Signature <br /> Month Day Year <br /> Lit PO 18. Transporter 2 Acknowledgement o1 Receipt of Materials <br /> 0 R <br /> U T Pr"edJTyped Name i Signature <br /> x E ! tf f r I Month Day Year <br /> - <br /> UT Discrepancy Indication Space <br /> FCA s <br /> I <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Nem 19. it i <br /> T r <br /> y Print edItyped dame <br /> Signature: i <br /> r Month Day Year , <br /> DHS 8700 A rsa) <br /> EPA 8700-222 Do Not Write Below This Line <br /> (Rev,9.88)Previous editions are obsolete. <br /> 9 <br /> r` YELLOW: GENERATOR RETAINS <br />