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Form Approved OMB No 1060--M39(Expires9 W �1 Toxic Substances Control Diriaiort <br /> Please print or type {Form designed for use on eh ,pitch typewriter) Sacramento California <br /> UNIFORM HAZARDOUS "ibrator s US EPA ID No Manifest Paget Information in the shaded areas <br /> WASTE MANIFEST Document No <br /> s � �, of Is not required by Federal taw <br /> 3 Generator a Nems and Mailing Address A State Manifest D cu e N m er <br /> SrGiC /o nl /1/1 S F <br /> ��',C S/4 �j f ,'�`r�'v J/���jo.✓.�A B State Generator a lD <br /> r.lr•Sfyv,t`/I S+(o3 ! .Srhr/I#Ali �7 <br /> 4 Generator a Phone( ) r. `�— ;f J; <br /> 5 Transporter 1 Company Name a US EPA ID Number C State Transporters ID <br /> ND Transporter a Phone <br /> Co 7 Transporter 2 Compan Nama 8 US EPA ID Number E State Transporter s ID <br /> Co 1 1 F Transporter a Phone <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Facility a!D <br /> V fit J H Facility a Phone <br /> 1 i2 ontaem 13 Total J 14 I <br /> 3 O in <br /> 1 t US DOT Description(Including Proper Shipping Name Hazard Class,and ID Number) Ouantity Unit Waste No <br /> No Type Wt/Vol <br /> e State <br />) Z G <br /> E EPAJOther <br /> N t t� t' -. r r' <br /> a R State <br /> 8 A <br /> T EPA/Other <br /> N <br /> e R c <br /> Scala <br /> EPA/Other <br /> IX I <br /> d State <br /> Z <br /> W <br /> V EPAJOther <br /> w <br /> Z J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> Oa - a b <br /> C d <br /> a <br /> Z <br /> a <br /> 15 Special Handling Instructions and Additional Information <br /> Z <br /> W <br /> J <br /> .J <br /> V 18 <br /> GENERATOR'S CERTIFICATION I 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 /> N 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 /> p 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 it I am a small quantity generator t have made a good faith effort to minimize my waste <br /> cl generation and select the beat waste management method that to available to me and that I can afford <br /> z <br /> uj Printed/Typed Name Signature Month Day Year <br /> vP T 14 A/ e <br /> u� <br /> tu T 17 Transporter t Acknowledgement of Receipt of Materials <br /> R <br /> 2 <br /> Z A Pnnted/Typed Name Signature Month pay Year <br /> N <br /> IL S <br /> p P r <br /> ua 0 IS Transporter 2 Acknowledgement of Receipt of Materials <br /> V T Printed/Typed Name Signature Month pay Year <br /> E <br /> Z_ <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> L <br /> 1 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by this marldest except as noted In Item 19 <br /> T <br /> PrmtedJTyped Name Signature Month pay Year <br /> DHS 8700 A(1/t;t3) <br /> EPA 8700-22 Do Not Write Below This Line <br />(Rev 9 88)Previous editions are obsolete <br /> YELLOW GENERATOR RETAINS <br />