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<br />Stele of Ceiltornle—f No, 2 and Welfare Agency 7 •-}� See Instructlons on Ba Page 6 ' ` Dep fnent of Health Services ,
<br />Form jproyed O B No, 205 1- 00 9 (Expires 9-30-9 L+z J Substances Control Division
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<br />P cess Nri 'jpr typd. F,'orm d9slgned for use on OM6 ( h fypbwrlfer). ' { ! . N\;" ''Sacramento, California
<br />UNIFORM HAZARDOUS
<br />1. Generator's US EPp"oto No. ..,,
<br />Manifest
<br />2. Paget
<br />Inlormetlon in thA shaded areae
<br />WASTE MANIFEST
<br />1;
<br />Document NoJ IL .
<br />of
<br />Is not roqulred by Federal law.
<br />3. Generator'd Name and Meiling Address
<br />A. Slate nifast Document Number
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<br />4. Generator's Phone L i8
<br />B. state Generator's 1D
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<br />6. Transporter 1 Company Name 6. US EPA ID Number
<br />C. State Transporter's ID
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<br />D. Transporter's Phone
<br />7. Transporter 2 Company Name US EPA ID Number
<br />E. Stale Transporter',, ID
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<br />F, Transportses Phone
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<br />9. Designated Facility Name and Site Address 10. US EPA ID Number
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<br />G, State Facility's ID,
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<br />11. US DOT Description (including Proper Shipping Name, Hazard Class, end ID Number)
<br />12. Containers
<br />3. Total
<br />Quantity
<br />14. ,
<br />Unit
<br />Waste NO +`
<br />110 a
<br />No. Type
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<br />J. Additional Descriptions for Materials Listed Above :
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<br />K. Handling Codes for Wastes Listed Above ;,, T
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<br />16. Special Handling inelructfone end Addlt one for' alto
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<br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately dasaflbbd�above by proper shipping name '
<br />and are classified, packed, marked, and labeled, and are in all In
<br />respects proper condition for transport by highpay according to applicable. international end
<br />national government regulations.
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<br />It 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 1 have determined,
<br />to be economically practicable and that I have selected the practicable method of treatment,
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<br />storage, or disposal currently available to me which minimizas 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 we ate
<br />generation and select the beat waste management method that Is
<br />available to me and that I can afford.
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<br />-Printed/Typed Name
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<br />Signa re Month Day Year
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<br />17. ransporter t Acknowleddement of Receipt of Materials
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<br />Printed/Typed Name
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<br />Signature Month Day Year
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<br />IS. Transporter 2 Acknowledoement of Receipt of Materials M
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<br />Printed/Typed Name " �.
<br />Signature Month Day Year.
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<br />19. Discrepancy Indication Space
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<br />20. Fa iiity Owner or Operator Certification of receipt of hazardous materials covered by hfa
<br />manliest except as noted In Item 19.
<br />`
<br />y Print d Typed Namea u e . Month Day Year
<br />t:
<br />DHS 8022 A Do I�lot Write Below This Line IV -
<br />EPA 8700-22
<br />(Rev. 6-89) Previous editions are obsolete.
<br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS
<br />
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