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State of California—Health 2 and Welfare Agency See Instructions on of Pa Department of Health Services <br />Form Approved OMB No. 2050-0039 (Expires 9-' 9e s p <br />and Front of : e 7 Toxic Substances Control Division <br />L Please print or type. Form designed for use on elite (12 -Hitch tveRwruarl 9o <br />DHS 8022 A <br />EPA 8700-22 <br />(Rev. 8-89) Previous editions are obsolete. <br />Do Not Write Below This Line <br />White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />To- P 0 Box 3(= 1;nrrmm&n4n rA oov) <br />- -- -- - <br />UNIFORM HAZARDOUS ,. Generator's US EPA ID No. Manifest <br />h D u nt N <br />WASTE MANIFEST 3 t <br />.qac amemv, Camvrma <br />2. Page 1 <br />Information in the shaded areas <br />(J <br />3. G nerator's Name and Mailing Address � <br />�� \ttLCCOkik 0ti 'iUl- l0tj �:lvv Dr -j ' <br />of t is not required by Federal law. <br />A. State Manifest Document Number <br />9051- <br />YuJ°1 ti 05w SLA\T.l9 sig "i � UN, <br />B. State Gen ora to <br />, <br />4. Generator's Phone ( �Itl _ q <br />7 <br />in <br />LO <br />� <br />5 Transporter 1 Company Name 8.I�A US EPA ID Number <br />T <br />, 6 7— <br />C. State Transporter's I"to <br />D. Transporter's Phone <br />LL <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID <br />O <br />F. Transporter's Phone <br />9. <br />a.(mee'and Site Address 10. US EPA ID Number <br />G. State Facility's 1D <br />D <br />Z <br />r <br />{D�'essiig�naat�eed�Faaciility <br />21 <br />2 A I � t�L—*r -/ O <br />V�b G� <br />H. Faci ty's P n® <br />x,10 3S— -Sct 3 <br />J <br />L <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. <br />Unit <br />I. <br />Waste No. <br />C4 <br />a. s bm F C�1L.f��%(%> F� 1C, �L.1 <br />No. Type <br />Wt/Vol <br />State <br />'7 <br />G <br />E <br />> N <br />' <br />, A—��cr-tt'-iY <br />C U`r ` T ' 1 Th <br />"Wot� 1 <br />(N�1 <br />E <br />b. <br />R <br />A <br />/ <br />State <br />o <br />D T <br />O <br />r <br />EPA/Other <br />V <br />t R <br />j <br />C. <br />State <br />EPA)CRher <br />i <br />d. <br />State <br />/ <br />EPA/Other <br />D <br />J. Additional Descriptions for Mstarlets Listed Above <br />K. Handling Codas fpr Wastes <br />Listed Above <br />b. <br />d. <br />15. Special Handling Instructions and Additional Information <br />{I��L -P&r 3-n4C-- J,p 2A- �v& <br />S*-6TT Y4uf'VWW-1-164� . li%oo 2-LI.76( <br />,5. <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, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and <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 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 <br />me which minimizes the <br />present and future threat to human health and the environment; OR, if t am a small quantity generator, I have made a good faith effort to minimize my waste <br />generation and select the best waste management method that is available to me and that i can afford. <br />PI ped Name Si Hat Month Day Year <br />T <br />R <br />17. Transporter t Acknowledgement of Receipt of Materials <br />A <br />N <br />Printed/Typed Name <br />Signature Month Day Year <br />S <br />P <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />T <br />E <br />Printed/Typed Name <br />Signature <br />g Month Day Year <br />,9. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />T <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />y <br />Printed/Typed Name <br />Signature Month Day Year <br />DHS 8022 A <br />EPA 8700-22 <br />(Rev. 8-89) Previous editions are obsolete. <br />Do Not Write Below This Line <br />White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />To- P 0 Box 3(= 1;nrrmm&n4n rA oov) <br />