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State of Calilomia—Health and Welfare Agency Department of Health Services <br /> Form Apnroved OMB No 2050-0039(Expires 9 30 91) Toxic Substances Control Division <br /> ' Please print or type (Form designed for use on stir 'pitch typewriter) Sacramento California <br /> UNIFORM HAZARDOUS Generator s US EPA ID No —y 12� Manifest 2 Page 1 information in the shaded areas <br /> WASTE MANIFEST L Q O L I 6.� �DgC>trjt¢nt o of is not required by Federal law <br /> 3 Generator a Name and Mailing Address �M1�,�,1 R7 Y� A State Manifest Document Number <br /> q-A 2>�aLrV,& `` tS 9016368 <br /> I A%k br,1X— qlHo3o B State Generator a ID <br /> i I 4 Generators Phone(y l'S) o Z-i H 3 Z <br /> 5 Transporter 1 Company Name � ` a US EPA ID Number C State Transporter's ID r0 <br /> �4Mer�Lav� �v►rn n1u.e r. �Ov� C ;3) ,q <br /> � 4 a S,a y g D Transporter's Phone <br /> N <br /> 'n 7 Transporter 2 Company Name 8 US EPA ID Number E. State Tranaporiar's ID <br /> Co <br /> O 1 1 1 1 1 1 1 1 1 1 1 F Transporter a Phone <br /> 9 Designated F cddy Mama and Site Address 10 US EPA 1D Number G State Facdtty s ID <br /> 1 Er U," , �7VC c v D o 9 y b 6 4 <br /> 25`� PArf` -e:,k\j d H Facility a Ph rte <br /> Z R\cNr�nohD CA �yao I A o Q LI � 9 <br /> 2 12 Containers 13 Total 14 I <br /> I 1 US DOT Description(Including Proper Shipping Name Hazard Class end ID Number) Quantity Unit Waste No <br /> No Type WtIVol <br /> U a -- ` „ Qin�l`1 p� State <br /> L`J'T• 1 �'6v� <br /> RMA <br /> Z GEPA10111er <br /> N mor e �u�� ha�u��dous wp�5le y <br /> soli o i o c7 <br /> E b State <br /> ni R <br /> m A EPMOther <br /> m T <br /> v O <br /> v R c State <br /> ' <br /> Co o <br /> EPA/Other <br /> w d State <br /> r <br /> Z <br /> !LI EPA/Other <br /> U <br /> J Additional Descriptions for Materials Listed Above } K. Handling Codes for Wastes Listed Above <br /> dleseR �ar� t <br /> 01 1 <br /> V-9-c, w,"i wdo 8y-\1 lLe. 4; LAI b c d <br /> a <br /> Z <br /> 0 <br /> 15 Special Handling instructions and Additional Information <br /> 4 <br /> W <br /> Y <br /> r <br /> ' J <br /> a to <br /> U <br /> GENERATOR'S CERTIFICATION 1 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 m proper condition for transport by highway according to applicable international and <br /> p, national government regulations <br /> a If 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 evadable to me whish minimizes the <br /> present and future threat to human health and the environment OR it I am a small quantity generator I have made a good faith effort to minimize my waste <br /> } generation and select the beat waste management method that is evadable to me and that I cart afford <br /> U <br /> �inted/Ty a Si �turMonth Day earUj Tor 1 1 16 <br /> W T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> Z <br /> Z A Printed! d Lawrie Signet u Month Day Year <br /> 0 <br /> Li- S oto 9 o <br /> 11J O 18 Trane orter 2 Acknowledgement of Receip of Materials <br /> R Printed/Typed NameSignature Month Day Year <br /> V T <br /> ' ER J <br /> Z <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 3 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/Typed Name Signature Month Dey Year <br /> DHS 8022 A(1188) Do Not Write Below This Line <br /> EPA 8706-22 Blue GENERATOR SENDS THIS COPY TO DOH5 WITHIN 30 DAYS <br /> n <br /> (Rev 9 88)Previous editions are obsolete \ _ <br /> ' To P 0 Box 400 Sacramento, CA 95812 0400 <br />