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State of California---Heallh and Welfare Agency Department of Health Serncr <br /> Form f pprove❑ OMB No 2050--0039(Expires 9 3� Toxic Suoslances Control Dw-sw <br /> Pleaserint Or Sacramento Caloorm <br /> p type (Form designed for use on eh gifts rypewrrter) <br /> UNIFORM HAZARDOUS Generator a US EPA 40 No Manifest 2 Page 1 Information in the shaded areas <br /> — <br /> WASTE MANIFEST Document No <br /> a <br /> + of not required by Federal law <br /> 3 enerator s Name and Wiling Address _ A State Manifest Document Number <br /> fd State Generator's ID <br /> 14 Generator a Phone(�' <br /> 5 T � J na orler Company Nem B US EPA ID Number C State Transporter a <br /> t- � r i P u ' / D Transporter's Phon ^ , <br /> N 4 <br /> 7 Transposer 2 ompany Name 8 US EPA ID Number E State Transporter a <br /> m <br /> o F Transporter a Phone <br /> m <br /> 9ji��``Oeslgnated F.cdtly Name and Site rAddr as 10 US EPA 3D Number G State Facility a tD <br /> a v <br /> U i H F cifity a Ph ria <br /> r <br /> z <br /> cc 12 Containers. 13 Tolal 14 t <br /> t t US DOT Description(Including Proper Shipping Name Hazard Class and tD Number) Quantity Unit Waste No <br /> J No Type VVI/Vol <br /> a J <br /> Slatg <br /> Z <br /> G EPA/Other <br /> E ( �. <br /> N <br /> E b Stats <br /> N R <br /> m A EPA 10ther <br /> CD T <br /> IT O <br /> 04 <br /> R c — State <br /> 0 <br /> m EPArOiher <br /> w d State <br /> Z <br /> U EPA/t7fher <br /> w <br /> rn J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> zs b <br /> �"�/ (/ t r <br /> r/ r' � 1 e d <br /> Z t= <br /> O <br /> 15 Special Handling Instructions and Addumnal Information <br /> z <br /> LU <br /> X <br /> J <br /> a ,s <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 /> 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 national government regulations <br /> til <br /> 11 If I am a large quantity generator I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> O to be economically practicable and that I have selected the practicable method of treatment storage or disposal currently available to me which minimize$the <br /> present and future threat to human health and the environment OR if I em a small quantity generator l have made a good laith 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 /> U <br /> ui Printed/Typed Name - n y Signature Month Day Year <br /> 1 t^ <br /> wT 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> R I <br /> A Pnnle yped Name Stgnatur �+ +' J Month Day Year <br /> LL S <br /> O p _ <br /> W O to rahaporter 2 AcknoArledgerfi6fill of Receipt of Materials <br /> in R PnnledlTyped Name Signature Month Day Year <br /> E <br /> z <br /> 19 Discrepancy Indication Space i <br /> F <br /> 1 C <br /> I <br /> L <br /> I20 Fecdd Owner or O orator Certification of receipt of hazardous materiels covere by this men at except noted m Item 9 <br /> T <br /> Y <br /> Panted Name Signator Mo Ili Day Y6ar <br /> DHS 8022 A (I e) } Do Not Write a Is Line <br /> EPA 8700-22 <br /> 1 (Rev 8 881 Previous ediiiana are obsol to _ <br /> r <br /> j Yellow TSDF SIN THIS COPY 14 GENERATOR WIT}{IN5 30 DA <br /> i j Y <br />