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mate of l;alnornla—ilealm aiw vvt wie nyaRll:y _ <br />Form proded OMB No. 2050-0039 (Expires 9-30-88) <br />` Please riot Form des' ned for use on elite (i ewriter . <br />UNIFORM HAZARDOUS <br />£Generator's US EPA ID <br />No <br />WASTE MANIFEST ,<� . <br />3. Generator's Name and Mailing Address <br />STo,dfn,E�$ SMC, ; <br />YS 7EiurE�PR�s-� sTj �re.�a.uT C.4 `SSS <br />4. Generator's Phone ( 4� <br />5. Transporter 1 Company Name 6 US EI <br />n _ <br />40 f 7.- Transporter 2 comilanj Name 8 US E1 <br />� <br />CD 9 Designated Facility:Name, and Site Address <br />US EI <br />/[t) <br />¢ l / yT/� <br />f) � „�;; 23/y (/. •) SS•, '� YuYi -T'': `//�-/ 7���r� ,R � <br />Z � <br />cc <br />z. <br />11 -US DOT Description (Including Proper Shipping Name Hazard pass and ID Nur <br />- Z aGt�•�ISTF �uP/ Os/i �'a��r3uS7.g%13�C'c sou e�/ <br />R <br />N1 4 a1�.-.! 953 t <br />o R b <br />410 <br />A F <br />v T - <br />ry <br />c R c <br />o : <br />cc r . <br />w <br />- <br />NP <br />Z <br />A <br />Toxic Substances Control Division <br />rix r ;i ,Sacramento, Califomia <br />n lfnt t , g nforma ion, wn h ded rtsa <br />sotepurr <br />A.*StateiWanifest;Documdrit Number. <br />q, <br />M" <br />fflate'Geinerat-'a <br />C StateTrattsporter 1D <br />Trtr(e hone <br />aria <br />12 Containers <br />13 Total <br />14. <br />t <br />Quantity .• <br />Unit <br />::.No. <br />Type <br />Wt/Vo <br />¢ <br />iJ <br />_ <br />by <br />0o <br />GENERATOR'S CERTIFICATION: I hereby declare'that the contentsof thf <br />consignment are lly and accurately described above proper shipping <br />J <br />=_name and are classified, packed; marked, and labeled and are to all res ets en proper.conddion for transport by highway according to applicable, <br />intemational and national government regulations 'f ;:; <br />;>. <br />Y <br />='If I am a large quantity generator, certify l.have a program in place_t <br />,reduce the volume and toxicity of waste generated to the degree I have ' <br />a <br />determined to be economically practicable and that .1 -have selected the <br />cticable:tiiethod of treatment;:storage,'or disposal currently available to <br />IF: <br />me which; minimizes the present and future threat4whumadfiealth and t' <br />environment ;OR ij am' a small quantity generator. I have made a good <br />a <br />i?a <br />'�fatth effort to minimae my waste generation and select the best -waste man <br />e <br />} <br />L <br />}} jw <br />l <br />LU <br />P ' t /Type me `- , ,,. <br />Signal re <br />Month Oay �Y r <br />�''s's� <br />Yg '`�,;�'p <br />Z <br />wEsF%Z !-7LouNS"+` ,¢foPrapria7� C e y <br />7' <br />¢ <br />iJ <br />_ <br />by <br />GENERATOR'S CERTIFICATION: I hereby declare'that the contentsof thf <br />consignment are lly and accurately described above proper shipping <br />J <br />=_name and are classified, packed; marked, and labeled and are to all res ets en proper.conddion for transport by highway according to applicable, <br />intemational and national government regulations 'f ;:; <br />;>. <br />='If I am a large quantity generator, certify l.have a program in place_t <br />,reduce the volume and toxicity of waste generated to the degree I have ' <br />.- <br />determined to be economically practicable and that .1 -have selected the <br />cticable:tiiethod of treatment;:storage,'or disposal currently available to <br />me which; minimizes the present and future threat4whumadfiealth and t' <br />environment ;OR ij am' a small quantity generator. I have made a good <br />'�fatth effort to minimae my waste generation and select the best -waste man <br />m n4 method that is available to me and that 1 can afford.: yy <br />}} jw <br />LU <br />P ' t /Type me `- , ,,. <br />Signal re <br />Month Oay �Y r <br />cc <br />:: <br />95L &e <br />r <br />s ! r <br />091 <br />LU <br />W T <br />1 r nsporter t Acknowledgement of Receipt Sif Materials- <br />i <br />R <br />Z A <br />Printed/Typed Name ,= <br />Signal 9 4 Month Day Year <br />N <br />S 1YJ d <br />b'. 18. Transporter 2 Acknowledg ent of Receipt of Materials r = <br />C T Printed/Typed Name Signature Month Day Year <br />U E <br />Z <br />19. Discrepancy Indication Space • <br />F <br />A <br />C <br />I � <br />L <br />1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in ftem 19. <br />Signature Month Day Year <br />T Printed/Typed Name <br />y i <br />DHS 8722 A (1/ 87) <br />EPA 8700-22 Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS INSTRUCTIONS ON THE BACK <br />(Rev. 9-86) Previous editions are obsolete_ To: P.O. Box 400, Sacramento, CA 95802 <br />-a. <br />