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Stater o14& ith and Welfare Agency <br />P'Fomi Approved OMB No. 2050--0039 (Expires 9.30 <br />See Instructions On B P <br />Front P <br />epartmeW of Health Services <br />s Control Division <br />SubsSac®amento, <br />Please Print of type. Form designed for use on elite rtch <br />typewriter). <br />and Of <br />California <br />UNIFORM H R®®LInC&V <br />1. Generator's US EPA ID No. <br />Manifest <br />2. Pepe 1 <br />WASTE MANIFEST <br />d <br />" <br />I'4' 3 <br />Information In the shaded areas <br />t <br />of <br />Is not required by Federal law. <br />3. G®e !ratoor`'s Name and Mailing ,Address <br />IM�WMNV� <br />A. Stats Manifest Numberp�/+��� <br />i11C�1 '1�Ve" <br />''•\`�� <br />( <br />0&'e0518718 <br />V% Cr t 1i r <br />4. Generator's Phone ( t <br />to Transporter 9 Company Name 6. US EPA ID Number <br />to� <br />N P 1 1%IGil t <br />U) 7. Transporter 2 Company Name 8. US EPA ID Number <br />m <br />0 <br />W <br />9. Designated Facility and Site Address <br />v tj I t4C <br />10. US EPA ID Number <br />Q< �Llan1 GA- <br />_4 <br />O 11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />Ll <br />= <br />E C, 5N1 FT Y* <br />Tk n1 <br />�3 N <br />'7 4v R b <br />A <br />CC T <br />o 1 <br />N R C. <br />8 i <br />¢ <br />W d. <br />t- <br />2 <br />W <br />U <br />W <br />N h <br />y <br />7M Nwiil" <br />¢`�' '=V)Uj <br />J 1 9 <br />Z <br />O <br />P 9S. Special Handling Instructions and Additional information <br />9 <br />Z JC -C o'�p Z 1� 2 G1--11TFZr <br />ujJ <br />< 96. <br />U <br />GENERATORS CE TitNl: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br />and aro ® classified. p�tmarked. and labeled, and are in all respects in proper condition for transport by highway according to applicable international and <br />IX If I am a large quantity generator, I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree t have determined <br />O to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available tome which minimizes the <br />U present and future throat to human health and the environment; OR, if 1 am a small quantity generator, 1 have made a good faith effort to minimize my waste <br />generation and selsel the beat waste management method that is available to me and that I can afford. <br />2 <br />Lu Name Snet Month Day Year <br />LU <br />RT 97. em <br />rensporter 1 Acknowledgment of Receipt of Materials <br />< NA P !Typed Name Sig Month Day Year <br />0o S 2 � L /1 / d „e <br />W O 98. Transporter 2 Acknowledgment of Receipt of Ma eriais <br />< T Printed/Typed Name Signature <br />Month Day Year <br />E <br />Z <br />19. Discrepancy kMication Space <br />F <br />A <br />C <br />L <br />1 20. Facility pwnw or Opera tbm f receipt tf hazardous materials cover this manifest except a ern 19. <br />T <br />Y reed MorHlt Da err <br />ONS am a Do Not W ' Bebw Thal litre <br />EPA 8700 —22 <br />(Rev. 8I Previous editions ars ®' : TSDF SENDS THIS ('t)PY T(1 fX�HS WITHIN IA nAYC <br />