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State of Gentorcma aalth and Welfare Agency See Instructions on B of Page 6 Department of Health Services <br /> Form Approved OMS No.2050--0039(Expires 930- and Front Of Toxic Substances Control Division <br /> Please print or tips. (Form designed for use on eli pitch typewriter). Sacramento.Calif arnls <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2, Page 1 Information in the shaded areas <br /> Document No. <br /> WASTE MANIFEST of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. Slate Manifest Document Number <br /> 88642358 <br /> S. State Generator's ID <br /> !. Generator's Phone( ) <br /> m <br /> 5. Transporter 1 Company Name 8. US EPA ID Number C. State Transporter's ID <br /> n D. Tren.Pon.,'.Phone <br /> N <br /> m L Transporter 2 Company Name 8. US EPA ID,Number E. State Transporter's to <br /> C9 <br /> F. Transporter's Phone <br /> m <br /> 9. Designated Facility Nanta and Site Address 10. US EPA ID Number G. Slab Facility's ID <br /> J <br /> J <br /> V H. Facility's Phone <br /> O<.xZ <br /> 4 12. Containers 13. Total id. I. <br /> y 11. US DOT Description(Including Proper Shipping Name,Hazard Class.and ID Number) Quantity Unit Waats No. <br /> No. Type Wt/Vol <br /> G <br /> E EPA/Other <br /> O3 N <br /> E b State <br /> ON R <br /> A <br /> of T EPA/Other <br /> N O <br /> a R C. <br /> Stale <br /> 8 <br /> m <br /> EPA/Other <br /> w d. State <br /> Z <br /> U EPA/Other <br /> 2 J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> O a. b. <br /> C. d. <br /> Z <br /> O <br /> � 15. Special Handling Instructions and Additional Information <br /> 2 <br /> 16. <br /> W <br /> J <br /> U <br /> GENERATOR'$CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and are classified.pecked,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> m national government regulations. <br /> 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 /> 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 bast waste management method that is available to me and that 1 can afford. <br /> Z <br /> Printed/Typed Name Signature Monts Day Year <br /> M <br /> w <br /> gW T 17. Transporter t Acknowledgement of Receipt of Materials <br /> Z R <br /> < A Printed/Typed Name Signature Month Day Year <br /> N <br /> I4 S <br /> o P <br /> O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> w <br /> t R Printed/Typed Name Signature - Month Day Year <br /> U E <br /> 2FI <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I <br /> T 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Rem 19. <br /> Y Printed/Typed Name Signature Month Day r. <br /> HS 8022 A(1/89) Do Not Write Below This Line <br /> ?A 87OD-22 <br /> ,Rev.9-88)Previous editions are obsolete. White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> VIII-6 To: P.O. Box 3000, Sacramento, CA 95812 <br />