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Form Approved OMB No. 2050-0039 (Expires 9-30 Toxic 'Substances 'Con't'rol'Division <br />lease' print or type. (Form designed for use on4pitch typewriter). 46 Sacramento, California <br />UNIFORM HAZARDOUS 1- Generator's US EPA ID No. <br />Manifest 2. Page 1 <br />Information in the shaded areas <br />WASTE MANIFEST , <br />1 <br />1 Document No. <br />of 1 <br />is not required by Federal law. <br />C-1 j 41--d L*J;J <br />3. Genepreor's Nar% and Mailing Address State Manifest D <br />fie,s Al 4 4 Sr <br />11,04eli T§b7§r <br />89 0 <br />PV 11 VC pA �OrU <br />-S11J-"S'd4A1,eb� <br />-1:?4-?4" B. State Generator's ID <br />Sro C./x"OV, e',l <br />4. Generator's Phone ( .1 C•I- <br />0 <br />S. Transporter I Company. Name a. US EPA ID Number C. State Transporter's ID <br />D. Transporter's Phone <br />111 gj �j j no <br />Go <br />7. 'Transporter 2 Compans(Nami a. US EPA ID Number' E. State Transporter's ID <br />9 <br />00 <br />1 <br />1 1 1 1 1 1 1 1 1 F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br />13 f Pe' r <br />C.) <br />rr H. Facility's Phone <br />-,-1 14 1 Z J'al 0 <br />M <br />0 <br />p <br />ainers <br />13. Total <br />14. <br />iL <br />11. US DOT Description (including Proper Shipping Name, Hazard Class. and ID Number) <br />Quantity <br />Unit <br />Waste No. <br />No. Type <br />I <br />L) <br />a. <br />State <br />Z <br />G <br />EPA/Other <br />E <br />T P- <br />N <br />- I <br />E <br />b. <br />state <br />R <br />gpNq <br />A <br />T <br />EPA/Other <br />N <br />0 <br />T <br />R <br />c <br />Stale <br />EPA/Otherit , <br />d. <br />state <br />Z <br />W <br />0 <br />EPA/Other <br />Uj <br />I <br />V) <br />Z <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />0 <br />a. <br />b. <br />W <br />M <br />C. <br />d. <br />Z <br />2 <br />16. Special Handling Instructions and Additional Information <br />Z <br />W <br />.j <br />.j <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 />(L <br />U) <br />national government regulations. <br />cc <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 />0 <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 />Z <br />Lu <br />Printed/Typed Name <br />Signature Month Day Year <br />Lu <br />14 A� <br />2 <br />LU <br />T <br />17. Transporter I Acknowledgement of Receipt of Materials - <br />R <br />Z <br />AN <br />Printed/Typed Name <br />Signature Month Day Year <br />S <br />P <br />. <br />Ai <br />0 <br />7187iian�sport11; 2 Acknowledgement of Receipt of Materials <br />:0 <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 />I <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />T <br />y <br />Printed/Typed Name <br />Signature Month Day Year <br />DHS 8022 A (1 /88) <br />EPA 8700-22 <br />(Rev. 9-88) Previous editions are obsolete. <br />Do Not Write Below This Line <br />YELLOW: GENERATOR RETAINS <br />