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State of California—+leelth and Welfare Agency Department of Health Services <br /> Form Approved OMS No.2050•-0039(Expires 9-30.911 Toxic Substances Control Division <br /> Piessla print or type. (Form designed for use on elite )itch typewriter). Sacremento,California <br /> UNIFORM HAZARDOUS ensrator's US EPA ID No. Manifest Page 1 Information In the shaded arses <br /> WASTE MANIFEST Document No. <br /> A It of is not required by Federal law. <br /> 3. Generator's Name and Melling Address A. State Manifeg D�cu ent Number <br /> 36292 <br /> S. State Generator's ID <br /> 4. Generator's Phone( ) <br /> n 5. Transporter 1 Company Nama, 8. US EPA ID Number C. State Transporter'&ID <br /> r1001 <br /> NDSCON E D. Transporter's Phone Al <br /> to 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> F. Transporter's Phone <br /> co <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> J <br /> �Q B.tickson, lac. <br /> 253 Parr Blvd, RiehnOndt CA 94 301 H. acs i Facility, Phone <br /> Q <br /> Z <br /> CC <br /> �0 12. Containers 13. Total 14. 1. <br /> t1 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. I Type Wt/Vol <br /> C a• State . <br /> U <br /> Z WASTEt )%KP TY 9TORAGE T;ijjX, 500 gallonlIl <br /> E CRLIFORNI A RB LiLF= WA&TR 01 LY EPA/Ot er <br /> 3 N <br /> E b. State <br /> o R <br /> co T EPA/Other <br /> < O <br /> Q R C. State <br /> co 0 <br /> 0 <br /> EPA/Other <br /> w d. State <br /> Z <br /> W <br /> U EPA/Other <br /> LU <br /> U J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> p a. b. <br /> al er-pty 'jaaolino tank too.;;!i 3ce3 with 15 The of dry <br /> 01 <br /> J d.iaa yer 1003 gal-Ions capacity <br /> a <br /> Z <br /> 0 <br /> F 15. Special Handling Instructions and Additional Information <br /> Q <br /> Z <br /> w <br /> 2 <br /> F- <br /> J <br /> J <br /> < 18. <br /> U <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 /> Nnational government regulations. <br /> If 1 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 /> p 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 /> U generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> W Printed/Typed Name Signature Month Day Year <br /> C7 <br /> U, r» <br /> wT 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Z R <br /> A Printed/Typed Name ., r f Signature /,' Month Day Year <br /> U.0 N ."i � { r � � �- X17 r 'l ` �'_>:�7 Jj J_Z j �G--�'• <br /> W PO 18. Transporter'2 Acknowledgement of Receipt of Materials }' I <br /> UT Printed/Typed Name Signature Month Day Year <br /> E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> L <br /> jy, <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Printed/Typed Name Signature Month DRY Year <br /> DHS 8022 A(1/88) Do Not Write Below This Line YELLOW: GENERATOR RETAINS <br /> EPA 8700-22 <br /> (Rev.9.88)Previous editions are obsolete. <br />