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..o••� �,ewinanpyyellareAgency } <br /> Form Approved OMB No.2050--0031)(Expires 9-30-9+1 Department of Health Services <br /> Please print or Toxic Substances Control Division <br /> p type. (Form designed for use on e!r' yitch typewriter). Sacramento,California <br /> UNIFORM HAZARDOUS enerstor's US EPA ID No. Manifest z. Page 1 i <br /> WASTE MANIFESTDocument No. Information in the.ahaded areas <br /> o! Is not required by Federal law. J <br /> 3. (3cneretor'a Name and Malting Address 1,0 1 <br /> J�� <br /> IN A. Slate Manifest Document Number <br /> J0114 IESTMA U)?II TRUSK <br /> i r► /! � ^! ,r; <br /> 27.E GrWI' LINE FMD TRACY, <br /> �'& 953� S. State t3enerator's ID ; <br /> 4. Generator's Phone( ) ` <br /> ,q 5. Transporter 1 Company Name I <br /> 8. US EPA !O Number C. Sae ranspo e e i <br /> t` ii I� l <br /> N D. Transporler'$Phone <br /> 7. ran po r"2 C ny QV 4yve <br /> i <br /> 8. <br /> UT E,A M Prurn or E. State Transporter's ID <br /> F. Transporter's Phone i <br /> 9. Designated Facility Name and Site Address t0- US EPA ID Number <br /> O. State Facility's ID <br /> �G(S,XS�L�WICES OF CALIFORNIA <br /> •S� l,1J V 1 �f SAS 1 H. Facility's Phone <br /> RJU 16 11 IS 17 la <br /> WHLJ <br /> US DOT Description(Including1-4. Containers 3. o{a 4• 1. <br /> Proper Shipping Name.Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt/vol <br /> r•* e. <br /> jp {y� ❑� State <br /> �+ E <br /> E ULIFORIIA PEfULATED WASTE 94LY— SMI RCPA <br /> N `I EPA10th <br /> E b. <br /> R 1' <br /> A Ste[ 1 <br /> .i <br /> v 0 EPA/Other <br /> N <br /> 7 R c. <br /> ara3� State <br /> T <br /> S z EPA/Other <br /> uuii d. <br /> Z ° State F <br /> w ' <br /> 1 EPA/01her <br /> i <br /> Z J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> O b. <br /> I <br /> SOIL OWN41NATED WITH OIL iASE a. <br /> CR <br /> J c- d, t <br /> 1 <br /> 1.- 15. Special Handling instructions and Additional Information • ;l <br /> WAR CMS, (,L(M ANI? BMTECTI ESI <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this co <br /> nsignmeni are lully 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 /> (L national government regulations. <br /> If 1 am a large quantity y I' p y 1) <br /> g q y ganerelor,I certil that I have a program in lace!o reduce the volume end toxicity of waste generated to the degree t have determined <br /> p to be economically practicable and that I have selected the practicable melhod']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 pond 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 /> .'i <br /> Printed/Typed Name - <br /> 7atur <br /> ei - Month Day Year ! <br /> l . <br /> R 17. Transporter I Acknowledgement of Receipt of Materiels i 1 <br /> Z l <br /> A Printed/Typed C Nama <br /> SignaturLLe <br /> N i Monfh Day Year <br /> O S '! <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materials y. <br /> R Printed/Typed Name naturer <br /> U E SI g i Month Day Year <br /> Z <br /> 19. Discrepancy Indication Space <br /> F <br /> A I <br /> C <br /> r <br /> L u' t <br /> ( 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manliest except as noted in Item f9. <br /> T <br /> y <br /> Printed/Typed NameSignaturei Month Day Year <br /> DHS <br /> 8700 A 2 r68) <br /> 8700 <br /> EPA —22 Do Not Write Below This Line <br /> - <br /> (Rev.9-66)Previous editions are obsolete. <br /> YELLOW: GENERATOR RETAINS <br />