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State of'California =Health and Welfare Agency ` <br />Form Approved OMB No. 2050-0039 (Expires 9-30-91) <br />Please print or type. Form designed for use on elite (12 -pitch typewriter). <br />Department of Health Services <br />See Instructions on b page 6. Toxic Substances Control Program <br />Sacramento; California <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. <br />WASTE MANIFEST /+ I p 1 1 0141 r 8141 JDAI <br />3. Generator's Name and Mailing Address <br />AT2M944 55IG D A M E R Q V HOSPITAL <br />09) 50 <br />525 W. ACACIA <br />4. Generator's Phone ( ) c r n ^U r nae n A e m a n— <br />P to a g&e e- L, It+'r 11,.31 I'& <br />7. Transporter 2 Comparry Name 8. US EPA ID Number <br />I I I 1 1 <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />CWM INC. <br />2301 W. BROADWAY ROAD A,Z,T , 0, 5 <br />Manifest Document No. 2. Page 1 <br />01 0 1 01 0 1 1 1 of <br />Information in the shaded areas <br />B not required by Federal taw. <br />DO NOT WRITE BELOW THIS LINE. V <br />DHS 8022A (12/90) <br />.� <br />Blue:' GENERATOR SENDS THIS COPY TO DHS WITMN 30 DAYS. ' <br />EPA 8700-22 <br />, <br />� . <br />Tai: Box 40k $cs ratite f1t6 C:A 45912-0400 <br />P <br />2 <br />,�'� <br />} <br />'_P.O. <br />