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State of Callfornle—ieelth and Welfare Agency ry <br /> Department of Health Services <br /> Form Awaved OMB Na 2050--0039(Expires 83091) Toxic DSubstances Control Division <br /> Please pant or type (Form designed for use on alit prick typewriter) Sacramento California <br /> UNIFORM HAZARDOUS Generator a US EP No Mamfes 2 Page t <br /> Information in the shaded areas <br /> WASTE MANIFEST r ,�--� caitrent o <br /> t of is not required by Federal law <br /> 3 GeneratCr�s IV{me and Mailing Address lip 1, � A State Manifest Documern Number <br /> 04 <br /> !til 1 baa e CGS. � u-t'Z> 90163611 <br /> 4 Generator Phone(LI I '} �1 Com. B at Genera a D <br /> Transport r 1 Com ny Nama ��` � tAp1}$ p lD�uptper, l C Stats Trianla Direr a Ip <br /> N r r `� y�v N�r M_) ` `,j + ul D 7ranbpaAer a Phone <br /> m 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter's ID <br /> ' F Transporter Phone <br /> 0 1 <br /> m <br /> 9 DeaignY-ti,Fa i!d sine and Site Address t0 US EPA ID Number G_$tate Facility a ID + <br /> S <br /> ►ch Moot ' °v q y i20 3 A Do c� 3Q " F l tr <br /> � Z L <br /> 12 Containers 13 Total t4 I <br /> iy 11 US DOT Description(Including Proper Shipping Name Hazard Class and 10 Number) Quantity Unit Waste No <br /> ¢ a No Type Wt/Vol <br /> = G �{+�f!1 r{�r [� State <br /> r E v/A1L.�e tt Y� r {(� �QS� �l}�\( EPA/Other <br /> 3 N 5 <br /> E b <br /> N R State <br /> A <br /> CD T <br /> N Q EPA/Other <br /> Ir R c <br /> ' 8 State <br /> m <br /> EPA/Other <br /> F' d State <br /> w <br /> ti <br /> Lu EPA/Other <br /> y J Additional Das i frons fa Maters s Listed Above i K Handling Codes for Wastes Listed Above <br /> �W �� RecA leci asd m le -4-a� a b <br /> zee ti �15-�r' #* -15 <br /> c d <br /> Z <br /> ' O <br /> 15 Special Handling Instructions and Additional information <br /> Z <br /> W <br /> it <br /> ' J <br /> J <br /> ¢ t8 <br /> V <br /> f GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> 1 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 /> ' W national government regulations <br /> ¢ If I am a large quantity generator f certify that I 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 disposat 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 faith effort to minimize my waste <br /> Z <br /> generation and aelew the beet waste management method that is available to me and that I can afford <br /> ' LU Pr.r. ted/Typeq Name Is .1/ r 5i <br /> ,}�—,'i r� lrlortA �f1a xea�y <br /> ¢ ,c vi leen j��Ytgr t,t }����i �t �r <br /> W <br /> WT IT Transporter 1 Acknowledgement of Receipt of Materials <br /> Z R <br /> ' ¢ A Pnnte d Name `, 5i at re U <br /> ay xe <br /> Lt. S 0 �, �� 17� (/�L"/f} <br /> W 0 t8 Transporter 2 Acknowledgement of Receipt of Matanet$ <br /> ¢ T Printed/Typed Name 7'� <br /> i <br /> ' V E Month Day Year <br /> z <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 120 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 A40h Day Year <br /> DHS 8022 A(1/88) Do Not Write Below This Line <br /> EPA 8700--.22 <br /> ' (Rev 9 88)Previous editions are obsolete Blue GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> To P 0 Box 400, Sacramento, CA 95812 0400 <br />