Laserfiche WebLink
Farm Approvad OM �Narexency <br /> B No.2058--Mag(Expires 9-30-^1) Department of Health Services <br /> Please print or type. (Form"Signed for use on c Toxic Substances Control Division <br /> pitch typewriler), Sacramento,California <br /> UNIFORM HAZARDOUS Generstor•,s US EPA ID No. Manifest 2. page t <br /> WASTE MANIFEST o t Information in the shaded areas i <br /> o1f is not required by Federal law. <br /> 3. Generator's Name and Melling Address , <br /> �'`iff� S � *� � !1 A. Stele Manifest Document Numbar <br /> 275 GPt+�A�f LI R TIiG CA <br /> B. Stara Generator 1D <br /> 4. Generator's Phone( ) 1 <br /> LO 5. transporter 1 company Name i <br /> LO <br /> 8. US EPA ID Number C. Slate Transporter'&ID <br /> 7. Transporter 2 Company Mame D. Transporter'&Phone <br /> 8. US EPA ID Number E. State Tranaporter's ID <br /> J; F. Transporter's Phone <br /> i I <br /> 9. Designated Facility Name and Sita Address li tD. US EPA ID Number O. Slate Facility's ID I <br /> Com'RVIU IF CALIFUR4IA - PWI <br /> U N "'^�' H. Fecltity's Phone 6 <br /> s">LtTT=1111 U A j CA `�5446 a 7 5 fi 3U5-762-7341 <br /> ' 11. US DOT Description(Including Proper Ship <br /> l t2. Container <br /> s14. 1. <br /> 0 p Aping Name,Hazard Class,and 11)Number) Unit Waste No. <br /> XfiJ I i <br /> No. tyWt/Vol <br /> �../UI�Fi�I�IA REt�..IWTED WASTE (A YI P"i RCRA i 0UI Y G � <br /> M� E <br /> N <br /> . ._ E b. <br /> CY R State <br /> T <br /> N O EPA/Other <br /> R c- <br /> Slate <br /> EPA/Other <br /> Q t <br /> W d. <br /> Z ' Stale <br /> U I f <br /> j EPA/Other <br /> J. Additional Descriptions for Materials Listed Above <br /> j <br /> _ �r� K. Handling Codes for Wastes Listed Above <br /> 4 SOIL CiITAl�II1�1T� if i T� OIL �3 ` . ' a. b, <br /> 1 <br /> C. d. <br /> Q a{ <br /> 'f <br /> 15. Special Handling fnalructlona and Additional Information .I <br /> " k <br /> LE � M <br /> WEAR 1-10VES, r(%ES g PROTLCTIV[ EqUIItENT , <br /> 11) <br /> 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,packed,marked,and labeled.and are in all respects in proper condition for transport by highway according to applicable international and <br /> CL <br /> netional government regulations. - t <br /> i; II <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 /> } <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 waste <br /> U general on and select the beet waste management method that Is available to.,jme and that I cart afford. <br /> Z h <br /> Printed/Typed Name Signature _ _ Month Day Year <br /> VU 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R I <br /> C A Printed/Typed Name I <br /> Signature <br /> N Month Day Year <br /> 0 P i. I <br /> LU O 18. Transporter 2 Acknowledgement of Receipt of Materials 'ir �y <br /> U] P <br /> Q R PrinledITyped Name Signature month Day Year <br /> U E Mh 1 <br /> Z i4 p <br /> 19. Discrepancy Indication Space , <br /> F <br /> A 3 <br /> C <br /> I t <br /> L i <br /> 1 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 I Typed Name <br /> Signature Month Day Year <br /> 1 <br /> DHS 8022 A(1/88) p <br /> EPA 8700---22 Do Not Write Below,This line <br /> (Rev.9-88)Previous editions are obsolete. it <br /> YELLOW: GENERATOR RETAINS <br />