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State of California—Heafth and Welfare Agency Department of Health Services <br /> Form Approved OMB No.2050-0039(Expires 9.30-r Toxic Substances Control Division <br /> Please print or type. (Form designed for use on alit ypawrifer). `w Sacramento,California <br /> �W UNIFORM HAZARDOUS1. Generator's US EPA ID No, Manifest 2. Page 1ument o No. Information in the shaded areas <br /> WASTE MANIFEST , i. „ of J is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> 5Gne�� <br /> B. State Generalor's1D4 <br /> tr (. <br /> W) 5. Transporter 1 Company Name e. US EPA ID Number C. State Transporter's ID Z, "r <br /> NRir,i,,,� ,r, D. Transporter's Phone <br /> W 7. Transporter 2 Company Name 8. US EPA-10 Number E. State Transporter's ID <br /> F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10, US EPA ID Number G. State Facility's ID <br /> U 13 -- N. Yli{�♦ �.� H. Facility's Phone <br /> 12. Containers 13. Total 14. I. <br /> LL <br /> I. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> ¢ No. Type Wt/Vol <br /> ; �:�,� %,ts. .A;s,' 1 (.•.,e:-} 3 k, t,. ' +ti .:r �•;,. :.,,, t,i <br /> State / <br /> G <br /> Et rot rV; "p i 'S' ti. EPA/Other <br /> E b. <br /> N R State <br /> m A <br /> m T <br /> N O EPA/Other <br /> R C. State <br /> D u` ■ EPA/Other <br /> W W Ir 1111 <br /> H State <br /> LU <br /> JUN 2 01989 <br /> W EPA/Other <br /> N -1 <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> E�A1 IRf�NMLNTAC*MRAN: 1-f ' [ ! {` a. b. <br /> l'rPFW, ITIS*R11� <br /> ir r.. <br /> J <br /> C. d. <br /> Z <br /> O <br /> Q 15. Special Handling Instructions and Additional Information <br /> Z <br /> W <br /> J <br /> J <br /> ¢ 18. <br /> L) <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 /> Il national government regulations. <br /> V) <br /> tL II 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 /> r 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 beat waste management method that is available to me and that I can afford. <br /> Z <br /> Printed/Typed Name SignatureIx Month Day Year <br /> W <br /> W T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Z R <br /> ¢ A Printed/Typed Name <br /> ILL N ure Signat <br /> r' Month Day Year <br /> O p r i( <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> W <br /> R Printed/Typed Name Signature <br /> E Month Day Year <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> L <br /> 1 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 Printed/Typed Name Signature Month Day Year <br /> DHS 8022 A 0/88) <br /> EPA 87007OD-22 Do Not Write Below This Line <br /> (Rev.9-8a)Previous editions are obsolete. <br />