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State of California—Health and Welfare Agency De0artment of Health Services* <br /> Form Approved OMB No.2050-0039(Expires 9-30.91) �` Toxic Substances Control Division <br /> Please print or type. (Form designed for use on elite(12-, 1 typewriter). Sacramento,California <br /> 1. Generators US EPA ID No. Manifest 2. Page 1 <br /> UNIFORM HAZARDOUS ' Information in the shaded areas <br /> '7 C <br /> Document No., <br /> WASTE MANIFEST J q of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> 8864H 45 <br /> � `7 1 X B. State Generator's ID <br /> 4. G'bFeratbr's)lhonei(�1 r") -,a`4� <br /> N 5. ansporter 1 Company Name J - 6 US E A ID Number C. State Transporter's ID <br /> e F. ,-t S Se R U)e'er C A d o 6 6 1 a t D. Transporter's Phone O <br /> N <br /> 'o 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> oF..Transporter's Phone <br /> OD I <br /> J9. Designated lity Nam�and�ite Address 10. US EPA ID Number G. State Facility's ID <br /> J <br /> , 3Z3HW/ 3 3 <br /> Lop <br /> 3 / 6 H. Facility's Phone <br /> TTS R5 o rJ c R 9S �3 A p o z�4 cY l <br /> 12. Containers 13. Total 14. I. <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt/Vol ' <br /> a. <br /> e Q' )i) rho L) 1 � ,L `� State <br /> 3 a <br /> N �� U ��-L Q T tJ D U � EPA/Other <br /> E <br /> b. Statecli /V <br /> ago A <br /> T EPA/Other <br /> N O <br /> o R c. j State <br /> OD <br /> EPA/Other. <br /> E <br /> w d. E\\ 1 it I 11E,'11-7*r <br /> F State , <br /> Z w PEFit h <br /> U [E-PA/Other <br /> W <br /> U J. Additional Doscri tions for M terials Listed Above K. Handling Codes for Wastes Listed Above <br /> z P q <br /> b. <br /> i'7�heS{1� j �r c. d. ' <br /> Q <br /> Z <br /> 0 <br /> F- 15. Special Handling Instructions and Additional Information <br /> Q <br /> Z <br /> W <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 heme <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 /> co national government regulations. <br /> cc 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 /> 0 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 faith 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 /> Printed/Typed Name Signature_ -, Month Day Year <br /> cc <br /> W TR 1.7 'Transp of I Ac wlEdgemAfR'of Receipt,of Materials - r <br /> Z A PrTyped NaTe <br /> N c v i9natu e �� Month Da x <br /> LLea <br /> 0 S <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> VR Printed/Typed Name Signature T 9 Month Day Year <br /> E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 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 <br /> Month 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: C -RATOR SENDS THIS COPY TO DOHS WITHIN.30 DAYS <br /> `Moe ��: 1-.0. Box A00, Sacramento, CA 95812-0400 <br />