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State of California --Health and Welfare Agency See Instructions on B Page 6 Department of Health Sorviceq <br />Form Approved OMB No. 2050,--0039 (Expires 9 -30 -Go and Front of Pitch Toxic SubstanceR ContrrCI Divisinn <br />Please print or type. jvorrh rqWgned for use on lit. , Pitch typ1l"ift). Sacramonto,enforai- <br />Ai <br />IMIFORM HAZARDOU enera or a 0 Manifest <br />-0 -0 IT Document No.motion <br />WASTE MANIFEST VI <br />12 2 <br />age Information In the shaded nrens <br />of is not required �y Federal law. <br />3. Generator's Name/and Litailing Address <br />fV (�okp. <br />A. Stat* Manifest Document Number <br />9 052167 <br />1 -To /V" � TX tv C- tg <br />State Generator's ID <br />4. Generator's Phone SAW?) <br />5. Transporter 1 Company Name' 6. US EPA ID Number <br />C. State Tr P6 ID <br />DILLARD Ic D1 121 al I I ill <br />", Phon <br />do84 6894---- <br />7. Transporter 2 Company Name 8.. US EPA ID Number <br />It. State raitapa, <br />t <br />1�.--TrM"ortoe. Phone <br />9. Designated Facility Name and Site Address to- US EPA ID Number <br />G. State Facility's to <br />Erickson. Inc. <br />I 1 .1 1 1 i 1 l._ 1 <br />:255 Parr Blvd. <br />Richmond. Ca. 94801 <br />-1v_1 <br />H. Facility's Phone <br />I C1 Al 121 Q1 91 2LILAU1 Al 91 2 <br />(A-- -.AR-113-0-111- <br />12. Containers <br />13, Total <br />14, <br />1. <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity <br />Unit <br />Walts No. <br />No. Type <br />Wt/Vol <br />a. <br />state 512 <br />G <br />Waste, Emty Storage Tank <br />1PA'Offt'hone <br />EN <br />Non RCRA Hazardous Waste Soild <br />0 0 1 <br />Ti P, <br />0101 510 12 <br />P <br />E <br />b. <br />State <br />R <br />A <br />T <br />FPA !Other <br />0 <br />R <br />C. <br />State <br />FFA/Other <br />d. <br />$Into <br />EPA/Other <br />J. Additional Deactijiff-oid far Materials Listed Above K. Handling Codes for Waste$ Listed Above <br />I WaSte ty Stara a tank,* With <br />15 lbs. dry ice <br />per 1.000 gallop <br />C. d. <br />IS. Special Handling Instructions and Additional Information <br />Keep away from sources ofIgnition. Wear hardhat, safety shoes <br />and gloves when working wit U.S.T.'s. Emergency Contact: 415-634-6850 <br />is. <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 me which minimizes 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 waste <br />generation and select the best waste management method that Is available to me and that I can afford. <br />Printed/Typed Name <br />P-9 <br />Signature Month Pay Year <br />epp, 7-0 <br />T <br />R <br />17. Transporter I Acknowledgement ofAecelpt of Materials <br />A <br />N <br />Printed/T d Naignature <br />A <br />Month Day Year <br />S <br />%f <br />ffiLi- 0 F <br />rl <br />I <br />P <br />0 <br />is. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature Month Day Year <br />E <br />R <br />19. 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 />Name <br />Signature Month Day Year <br />DHS 8022 A Do Not Write Below This Line <br />EPA 8700-22 <br />(Rev. 6-89) Previous editions are obsolete. <br />Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />To: P.O. Box 400, Sacramento, CA 55812 0400 <br />