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State of ColkomkrHeolth and Welfare Agency <br />Phase print or type. `''form designed for use on elite (10 typewriter).See Instructions on ba&f <br />page 6. <br />UNIFORM HAZARDOUS 1. Generators LIS EPA ID No. Manifest Document No. P <br />WASTE MANIFEST1CIAIDl9i8iji6i7i4i6i(I I » <br />3.Gand Mailing enotcdors Name an�yM�aiilin>g AAdddress��yn and <br />1=35"L <br />4PGer»ralo. FAX dhor22SO4 exs5,.z�i ''t= �pCLj �,aa 95822 a State, nerd <br />1 Company Name - 6• US <br />Department of Health Servi <br />Toxic Substances Control Prog• <br />Sacramento, Calico <br />1 information Is the shaded areas <br />Federal lax. <br />7. ransporter 2 Company Name 8. US EPA ID Number E.' StClo Tron%portots ID <br />9. Designated Fociffy Name and Sae Address 10. US EPA ID Number <br />PEXPIMM ROMM R <br />CN <br />133M NOM BXG%W 33 H• <br />O 0 i 1 I t i l l l l l l <br />11. US DOT Description (Including Roper Shipping Name, Hazard Class, and 10 Number) 12. ContainersNo. T <br />r�,,tr .{.•-••,:r r• ,troy Corporatior, certifies ;{,ra <br />h c R. t <br />pct lar,lr were recycled ., <br />o=)t,vc,, Was ycled Ir; <br />I prow io-i:.:,(.-40CFR2.61 ' and 23.4 1 r <br />•I Z <.. t C1t' •� -,.: �:. ••l C: J "t tV,1 c;,1c 11i'rl the •'.1! r. ,.r•�ii ': •r. <br />(Pe ,yc!ed In accordance with the provision ";:� „� <br />R on of E: ;;- L <br />A 6i <br />d. PETROLEUM RFCY(-: <br />O <br />ria - <br />N <br />B Y <br />I I <br />J Addalorsd pesrrnptiorn for ferlafs �.MedAbove , K Fk <br />+); M + <br />,y :»s: <br />Z <br />U 15. Spec ioiHondlingInstructions and AddabnalInformation LIU <br />Lu7Mal <br />01�a <br />13. Total 14. Una <br />avant' WtNol <br />w » �� > � MAY ®7 EMM4. (64 LJ d (1� <br />CL <br />J <br />Q 16. GENERATORS CERTIFICATION: I hereby declare that the cCn4 oo((♦ IWFp�accurately doscribod above by proper shipping name and are classified, <br />Z packed, marked, and labeled, and are In all respects in proper co AOr't's Y t, cording to applicoble international and national ovornment <br />O Iv1'i g regulations. <br />Q If 1 am a large quantity generator, I certify that I have a program In place to reduce 1ho volume and toxicity of wasto genorated to the dog i have detornnod to be <br />economically practicable and that I have selected the practicable method of troatmont, storage, Z P ago, or disposal currently Wailabke to mo which minimizes the present and future <br />LL, throat to human health and the environment: OR. N 1 am a small quantity generator, I have made a good faith effort to minimpe rry waste generation and select the best waste <br />T management method that Is available to me and that I can afford. <br />r - <br />J <br />4 <br />Printed/typed Name <br />Signature <br />U <br />J <br />y` <br />. {CArL12t. <br />s .�T.+ <br />C <br />T <br />17. Transportor 1 Acknowledgement of Receipt of Matorlals ! <br />O <br />R <br />A <br />Printed pod Name <br />Slgnature <br />U <br />N <br />aO <br />18. Trans iter 2 Acknowiedgement of 14,oijot of Matorklls <br />> <br />RPrinted/typed <br />Name <br />Signature <br />Lu <br />T <br />E <br />R <br />Lo <br />N <br />� <br />19. <br />F <br />Discrepancy Indication Space <br />1. <br />1 20, <br />Facility Owner or Operator Certification r receipt of hxscaraous matorlols covered by this monffest except as noted in Nem 19. <br />T Printed/Typed <br />Name Signaluro <br />r <br />kl- - <br />LO <br />DHS 8022A (12/90) <br />EPA 8700-22 <br />WRITE BELOW THIS UNE. <br />1212121%13 <br />Month Lary year <br />012 17 nJ91 13 - <br />Month Lary yea <br />T,'DF S NDS TI IIS COPY TO GENERATOR WITHIN 30 DAYS. <br />��s�t <br />