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• Slate or Californialeelth and Welfare Agency "v -� � � � � � �-�~ � � � <br /> Department of Health viCk <br /> Form Approved OMB No.2050--0039(Expires 8 ) + <br /> Toxic Substances Control DlDiviii, <br /> Please print or type. (Form designed for use an*lits(12-pitch typewrfter). Sacramento,Celiforn <br /> i UNIFORM HAZARDOUS I 1. Generator'a US EPA iD No. j Manifest 2. Page 1 Information In the shaded areae <br /> WASTE MANIFEST Document No. <br /> I o} Is not required by Federal law. <br /> 3:rGenerator's Name and Mailing Address %J A. State Mantlest Document Number <br /> i <br /> State Generatoea ID <br /> 4. Generator's Phone(""g, "► (/, <br /> o 5. Tjap ar 1 mp Name 8. US EPA ID Number C. Skate Traneporter's I [/ <br /> /H( ,C <br /> ,tq / 2 D. TraneIV?tZporter'e Phon_r2j(21-71S-1/ 1 <br /> o T. Transporter 2 Ca arty Name 8. US EPA ID Number E. State Transporter*s IO <br /> oF. Transporter'a Phone <br /> 9IDesignated Facility Name and Site Address 10, US EPA tNumber G. State Facility's ID <br /> I <br /> f�i H. Facility's Phone <br /> 12. Con7ineA3 13. Total 14. I. <br /> 11 US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> J / l !�, / r p l NO. Type Wt/Vo! <br /> G a. State <br /> -VVlrfa�G - i 1 (�.4-1ijG�+� L <br /> c! <br /> N a — EPAICNFier <br /> 1 77 <br /> E b. <br /> v R State <br /> U <br /> A <br /> y T EPA/Other <br /> s O <br /> i R C.� Slate <br /> EPA1OIher <br /> C <br /> _3 d. State <br /> I <br /> J <br /> EPA/Other <br /> ` J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> 4a11,C1CI-k s. b. <br /> Q <br /> C. d. <br /> 5 `% . � <br /> i <br /> 15. Special Handling Instructions and Additional Information <br /> u - <br /> a ' <br /> � T8. <br /> t <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper,shippingname <br /> a .and are classified,packed,marked,and labeled,and are in aft respects in proper condition for transport by highway according to applicable international and <br /> i <br /> '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 weeks generated to the degree I have determined <br /> j 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 10 minimize my waste <br /> generation and select the beat waste management method that Is available to me and that I can afford. <br /> Printed/Typed Name Signature Month Day Year <br /> 7 _ <br /> i <br /> i T 17. Transporter t Acknowledgement of Receipt of Materials <br /> R <br /> A Printed/ Name Signature „- Month Day Year <br /> N4 Ile <br /> :: <br /> 1 0 18. Transporter 2 Acknowledgement!of Receipt of Materials <br /> 1 R <br /> Signature <br /> Printed/Typed Name SI u <br /> j T g ,.,;1 -+� r!`� r Month Day Year <br /> E - <br /> 19. Discrepancy Indication Space u es3 <br /> lJkiP - <br /> F <br /> JAN 2 g <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as IToted•t11t�IBn1 <br /> T <br /> y Printed/Typed Nam Signature r Month Day Year <br /> IS 8022 A(1168) Do Not Write Below _s•dine - <br /> 'A 8700-22 , <br /> •ev.9.88)Previous editlons are obsolete. <br /> Yellow: TSDF SENDS THIS'COPY TO C=r"JERATOR WITHIt <br />