Laserfiche WebLink
mn <br />Q <br />C <br />L <br />z <br />I- <br />3 <br />CF)N <br />00 <br />00 <br />v <br />N <br />v <br />0 <br />0 <br />m <br />cc <br />W <br />I - <br />Z <br />w <br />U <br />rd <br />State of California—Health and Welfare Agency See Instructions On B f Page 6 Department of Health Sorvices <br />Form Approved OMB No. 2050-0039 (Expires 9.30• Toxic Substances Control Division <br />Please print or g and Front Of P <br />p type. FoAm designed /or use on elite itch typewriter). Sacramento. California <br />DHS 8022 A <br />EPA 8700-22 <br />(Rev. 6.89) Previous editions are obsolete. <br />Do Not Write Below This line <br />' I,r. TRAT()R SENDS THIS COPY TO DONS WI -MIN 30 DAYS <br />To. P.CI• Roy 400, Srrrnmento, CA 5591? 0400 <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1 Generator's US EPA ID No. Manifest <br />� � � Tit <br />2• Peg <br />� <br />1 <br />Information in the shaded areas <br />VIg 1e <br />of <br />of <br />is not required by Federal law. <br />3. Generator's Name and Mfiling Address p�ntj• <br />V'S t.�AVAt [ UMMUNI(AApN cAct�r� <br />A. State Manifest Docum Mel <br />l 23 <br />'VuVJ; A j��i%1>� %5l.6Ni9 '3iLCVjbI,, ,F'cYrA � <br />0 <br />a. State GenerAfef'p 1 <br />4. Generator's Phone (rx <br />�(,) q ILL5 � L•i <br />ri <br />i <br />5. Ta spo ter 1 Company Name 6. US EPA ID Number <br />�1 L F�(_ -j - <br />1 <br />C. State Transporter's ID <br />D. Traneporter'e Phone <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID <br />i <br />i <br />F. Transporter's Phone <br />9.�t signated Facility Name and Site rasa 10. US EPA ID Number <br />MVM CIL 'Ft MN1"`'q <br />G. State Facility's ID <br />i <br />Ty cr Cidw OJ �'( I A t,_ _V � <br />133o C `D `t� `tl <br />H. F iUt 's Ph e <br />�`� <br />x Ftp , CA . % r � � 11 1 <br />0'S 3Z3 - <br />i <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and fD Number) <br />12. Containers <br />13.QTotal <br />uantity <br />14. <br />Unit <br />I. <br />Wast® No. <br />No. Type <br />Wt/Vol <br />a• e. I �N �i'�. IG 1`1 kAC. Woo 1) <br />'+ <br />State. <br />G <br />N <br />r•�7 �x <br />Vii t C `t_ ��y 1�7 ()(( ."�� <br />- y <br />0% L. � <br />C"` <br />t� <br />EPA/Other � t� <br />E <br />R <br />b. <br />State <br />A <br />T <br />O <br />EPA/Other <br />R <br />C. <br />State <br />EPA/Other <br />d. <br />State <br />EPA/Other <br />J. ®Additional Descriptions for MCaaterials1 Listed Above <br />K. Handling Codes for Wastes Listed Above <br />a. b. <br />C. <br />d. <br />15. Special Handling Instructions and Addition Information <br />Pe0TVLTjQ <br />16. <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 J)overnment 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 1 have determined <br />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.1 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 av ' e and that 1 can afford. <br />R ,' Typed Name Month Day Year <br />is (� t 1 / %%l'..9 <br />T <br />R <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />NPrinted <br />/Typed Name S' _ Month Day Year <br />� Al0t_�.5 t- ir1i� /�j � <br />P <br />, rr llC� < 12 1 <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />1 <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. 6.89) Previous editions are obsolete. <br />Do Not Write Below This line <br />' I,r. TRAT()R SENDS THIS COPY TO DONS WI -MIN 30 DAYS <br />To. P.CI• Roy 400, Srrrnmento, CA 5591? 0400 <br />