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State of California—Health and Welfare Agency - Department of Health Service <br /> Form/.pproved OMB No.2050-0039(Expires 9-30 Toxic Substances Control Divis,u <br /> Please print or type. (Form designed for use on elia pitch typewriter). Sacramento,Caliform <br /> UNIFORM HAZARDOUS ,Generator's US EPA ID No, Manifest 2, Page 1 Information in the shaded areas <br /> Document No. <br /> WASTE MANIFEST , �I / of is not required by Federal law. <br /> 3 eneralor's Name and iling Address A. State Manifest Document Number <br /> �� .:.1�`� 93739 <br /> h( .�• `'I �/ *"`�! 8. State Generator's tD <br /> 4. Generetor's Phone ^ f <br /> f _ r <br /> 5. T ns orter Com any Nem . 8. US EPA ID Number C. State Transporter's 1101. <� ':1 <br /> 9 P <br /> `o 1 / p J <br /> N� /— / <br /> L ' ' /; (" 1-,?kD. Transporter's Phon •^, y; !. <br /> N 7. Transporter 2 ompany Name 8. US EPA ID Number E. State Transporter's <br /> rA <br /> F. Transporter's Phone <br /> 0 <br /> m <br /> 9. esignated Facility Name and Site Add r ss 10. US EPA ID Number G. State Facility's ID <br /> 41 <br /> U H. Fcility's Ph ne <br /> N ¢ 12. Containers, 13. Total 14. 1. <br /> M Ow 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Ouantity Unit Waste No. <br /> J <br /> No. Type Wt/vol <br /> a. 1 ' ' sta� <br /> G EPA/Other <br /> C H N 414 <br /> 3 E b. '' ( •�� - / State <br /> O A <br /> 03 T EPA/Other <br /> P O <br /> (V <br /> .F R C. State <br /> 0 <br /> 0 <br /> co -- <br /> EPA/Other <br /> Cr d. State <br /> F- <br /> Z <br /> W <br /> U EPA/Other <br /> W <br /> U) J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z / <br /> b. <br /> o <br /> CL <br /> w <br /> tr �— j f d. <br /> Z <br /> 0 <br /> F 15. Special Handling Instructions and Additional Information <br /> Q <br /> Z <br /> W <br /> f- <br /> J <br /> J <br /> Q 16. <br /> U <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J 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 /> 0. national government regulations. <br /> X. II 1 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 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 laith effort to minimize my waste <br /> U generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> WPrinted/Typed Name Signature Month Day Year <br /> WT 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Z R <br /> Q N Prints yped Name Signal ur ; Month Day Year <br /> U. F <br /> W O 18. Tra,h6porter 2 Ackno%Wedgerfient of Receipt of Materials <br /> Q R Printed/Typed Name Signature Month Day Year <br /> U E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I "Facilner or O orator Certification of receipt of hazardous materials covers by this men' st except noted in Item 9.T <br /> y Neme Signature Mo/rfh Day Y6er <br /> / f � <br /> DHS 8022 A(18) ! Do Not Write o his Line <br /> EPA 8700-22 <br /> (Rev.9.88)Previous editions are obsof te. <br /> Yellow: TSDF SEN THIS COPY TO GENERATOR WITHIN 30 DA` <br /> , l . <br />