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State of Caktorria--Heahh and Welfare Agency <br />form Approved OMB No. 2050-0039 (Expires 9 -30 - <br />PI.... — <br />-30 Pte rinr <br />Toxic Substances Control Division <br />.Sacramento, Caldomia <br />DHS 8022 A (1187) INSTRUCTIONS ON THE SACK <br />EPA 8700-22 - - .. .. - .. .. .. ... -, <br />(Rev. 9-86) Previous editions are obsolete. J. _ .,.. "t• ,, ,., _.:..:.' �• �..•, - <br />IN CASE OF AN EMERGENCY OR SPILL. CALL THE NATIONAL RESPONSE CENTER 1.800-424-8802: WITHIN CALIFORNIA CALL 1-800-852-7550 <br />Generator's US EPA ID No. Manifest <br />UNIFORM HAZARD <br />2. Page 1 Information in the shaded areas <br />Document <br />L. Document No. <br />WASTEMANIFEST <br />of is not required by Federal law. <br />3. Generators Name and Mailing Agprese <br />A. State Manifest Document Number <br />�.�. 5r 11f/6_!Hci s <br />1 `3 44 <br />( Ory S ! -' <br />_ <br />B. State Generator's b <br />4. Generator's Phone t%/S ) ., c C <br />5. Transporter t Company Name 6. US EPA 10 Number <br />C. State Transporter'& 9) <br />)i� v f. % <br />D. Transporter's Phone <br />Z 2212 <br />7. Transporter 2 Company Name 8, US EPA 10 Number <br />E. State Transporter's ID <br />F. Transporter's Phone <br />9. Designated Facility Name qnd Site Addretsp 10. US EPA 10 Number <br />G. State Facility's ID <br />e-4S.-tlryl-4o)7 .ee 5�..�t�c S <br />it/T✓ i.'G�a-� <br />I I ILL <br />H. Facility's Phone <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 />Waste No. <br />No. Type <br />Wt/vo <br />a. 2 A k'OG <br />hq lllg57C/ SfaCC.%� ,(/�S. D��!`- <br />State 67 // <br />/ <br />G <br />E <br />r. f `) Cider <br />EPA/Oth <br />NI <br />al <br />E <br />b. <br />State <br />R <br />A <br />EPA/Other <br />T <br />RC. <br />State <br />EPA / Other <br />d. <br />State <br />¢ <br />EPA/Other <br />J. Additional Descriptions for Materials Listed AboveC{ f <br />K. Handling Codes for Wastes <br />Listed Above <br />�/ <br />1""W��` %17�•, rim:-t(�f/, <br />a. <br />b. <br />I �LL1I✓/f7Tl�•� <br />/! f <br />C. <br />d. <br />15. Special Handling Instructions and Additional Information <br />/ r• : ' ff: rr,:', iL".'" s1c!' r'i •..l�.ti [t�/.�. �/ ; ✓rriJ"till <br />/ 2 � <br />/ f <br />iVt%ir �lcrlr `__ tip' . ` <br />f 1 I l i ! <br />16. <br />GENERATOR'S CERTIFICATION: t hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br />name and are classified, packed, marked.- and labeled, and are in all respects in proper condition for transport by highway according to applicable <br />international and national government regulations. <br />I1 I am a large quantity generator, 1 certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have <br />determined to be economically practicable and that I have selected the practicable method of treatment, storage• or disposal currently available to <br />me which minimizes the present and future threat to human health and the environment; OR. if 1 am a small quantity generator, I have made a good <br />faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. <br />Printed/Typed Name <br />Signatvre Month Day Year <br />T <br />R <br />17. Transporter t Acknowledgement of Receipt ol Materials ' <br />A <br />Printed/ Typed Name <br />Signature Month Day Year <br />O <br />8. Transporter 2 Acknowfedgement of Receipt of Materials <br />R <br />T <br />Printed/Typed <br />yped Name <br />Signature Month Day Year <br />' <br />E <br />t9. Discrepancy Indication Space <br />F <br />1 <br />A <br />, C <br />1 <br />1 <br />20, Facilely Owner or Operator Certification of receipt of hazardous materials covered by this manifest except ds noted m Item 19 <br />T <br />LYI <br />Printed, Typed Name <br />Signature Month Day Year <br />III111 <br />DHS 8022 A (1187) INSTRUCTIONS ON THE SACK <br />EPA 8700-22 - - .. .. - .. .. .. ... -, <br />(Rev. 9-86) Previous editions are obsolete. J. _ .,.. "t• ,, ,., _.:..:.' �• �..•, - <br />IN CASE OF AN EMERGENCY OR SPILL. CALL THE NATIONAL RESPONSE CENTER 1.800-424-8802: WITHIN CALIFORNIA CALL 1-800-852-7550 <br />