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De0artment of Health Services <br /> State of Caliiornia—Health and Welfare Agency Toxic Substances Control Division <br /> Forth Approved OMB No.2050-0039(Expires 5-30-91) <br /> ,�. Sacramento,California <br /> Please print or type. {Form designed for use on efit i '!ch typewriter). <br /> UNIFORM HAZARDOUS ,, nerator's US EPA ID No. Manifest . Page 1 Information in the shaded areas <br /> Document No <br /> WASTE MANIFEST . 1 <br /> of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> "'^'V EMAM V= 0, State Generator's lD <br /> 4. to e(U h r W. TRACY (A, 55376 <br /> 5. Transporter 1 Company Name f3. US EPA ID Number C. tate rensportis HLA I HI Q1 31610010111412171 ) <br /> L- r' <br /> u> <br /> o D. Tranaporter'a Phone <br /> l 01 S1 2151 <br /> ' 4 7. MAMr om a m tPAID r ' l : 4 r T 1 <br /> F- Trarisporter's P-tRon <br /> o <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number - G. State FacillYy's It) <br /> "� 11 <br /> < C-Sn SERVICES OF WFORdA ii H. Facility's Phone <br /> "' 2. Conlainers1 oto `{ I. <br /> �V f 1. US DOT Description(Including Proper Shipping Name,Hazard Class.and ID Number) Quantity Unit .� Waste No. r <br />' rt No. Type Wt/vol <br />{ -46 n. State <br /> a I--jX_ E CALIR)RAIA REGMTEQ AM (XV — W4 RCRAG 0 Q T it ? Q Q Y EPAID. <br /> N.� <br /> E b. Stale i <br /> o R <br /> A <br /> T EPAf Other <br /> N <br /> o R c. State <br /> C9 {I <br /> EPA/Other <br /> I Cr i <br /> 9 f- d State <br /> 14 Z <br /> U EPA/Other <br /> w <br /> Z J. Additional Descriptions for Materials Listed Above <br /> p K. Handling Codes for Wastes Listed Above <br /> O �. b- <br /> W 331CUKAMMM WITH GWEPAE AN6 OIL- <br /> 2 <br /> C. d. i <br /> J <br /> Q <br /> Z <br /> 15. Special Handling Instructions and Additional Information <br /> a = <br /> Z <br /> MT.ILE <br /> HEM ()MES, GOWLES MU FOTECTIVE LQUIMT <br /> U <br /> ,6 <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping Hama <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 /> 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 /> p to be economically practicable and that I have selected the practicable method of treatment, storage,or disposal currently available io ma which minimizea the <br /> >. present and fulure threat to human health and the environment;OR,if I am a small quantity generator.I have made a good faith effort Io minimize my waste <br /> U generation end select the best waste management method that is available to me and that I can afford. <br /> z <br /> w PrintedITyped Name Signature g Month Day Year <br /> Lu <br /> w T 17- Transporter f Acknowledgement of Receipt of Materials II <br /> R <br /> ¢ N PrintedlTyped Name Signatute - Month Day Year <br /> u_ 5 - 1 r !� <br /> p "� - j r' 1 <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materials ' <br /> QR PrintedrTyped Name _ <br /> e U E Signature Month Day Year <br /> Z R <br /> 19. Discrepancy Indication Space s i <br /> F <br /> A <br /> C <br /> I <br /> L !1 <br /> t 20. Facility Owner or Operalor Certification of receipt of hazardous materials covered by this manifest except as noted in Ilem 19. - <br /> T <br /> y Printed/Typed Name Signature Month Day Year <br /> DHS 8022 A(1 188) DO Not Write Below This Line <br /> EPA 8700-22 " <br /> (Rev.9-58)Previous editions are obsolete. - <br /> - YELLOW: GENERATOR RETAINS <br />