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State Of C01,10rnra—Health and Wedare Agency , <br />Form OMB No. 2050-0039 ( 9-3491) See Instfucti4f�S Oft IC of page t3. <br />Plemprint or type. F'arrm dewried br use Ort @lite Ch 'fere f , <br />UNIFORM HAZARDOUS 1.Generaws,USEPAVNo. i t neat. ,xn N9. 1 2 Pogo <br />WASTE MANIFEST G 4 A 91 8, 11 <br />'�` i i{ t (, 1 1 <br />3. Generators Nome and Ares of <br />A -}"} n— t;r1? A. Stale Montest Doc <br />4. Generator: Phare < ?^`?j > t ' r • Store 6ererotoo s C <br />"? 0 - 3 ' •? H <br />C. Stole Transporter sI <br />tY4, t <br />1710113P-1-1 1 Company Name 6. t$ EPA ID Number <br />PRC PATTERSON, INC. Q <br />C 1 A ID 19 18 11 16 19 16 14 2 10 teon powers Phone <br />1. Transporter 2 Company Name 8. US EPA ID Number <br />C-Stcte Trarripofters C <br />Id)�naattf I I I I I I I I I I <br />9 p,, Ind 10. U5 EPA ID Number <br />eL <br />T <br />R <br />3 N HWYM <br />Pnhted/ryped Name SignatureU <br />PATTERSON, CA 95363 <br />CIA ID 10 18 <br />_ <br />11- US DOT Description (rsckrdhg Proper shipping Nome. Ha¢ad Coss, and ID Number) <br />'J <br />,�U <br />G <br />a. <br />/ti'VM /�t..h..e''� �-/}•�/'�'lv�l`LCi T-•u/'i'S'a'A�. i..l �tlll. <br />18. Tract er 2 Acknowte t of Rete' t of Material <br />Prirteollypedvane <br />E <br />E <br />M c0 <br />E <br />b. <br />R <br />R <br />Q7 U <br />A <br />CO z <br />T <br />C. <br />19. Discrepancy hdi=ion Spa® <br />O <br />R <br />.nn <br />N\ <br />A <br />C <br />Lus <br />CL <br />N <br />20. FacAitY Owner or Operator CeRAtcation of rece mofenCh covered by ft rt <br />Prknted/Typed Name <br />Y <br />t: Adtlrtond Desra+pfarm for Moterre Ur "17d Abovs77777777777777 <br />Lu <br />XC <br />W <br />13_11 16 16 17 9 18 <br />12. Cont< <br />No. <br />Department of Health Se,,iCL. <br />Toxic Substances Control Progror, <br />Sacramento. Cdifo nlc <br />fmom+atbn in the snorted areas <br />is not required by Fecfepal jaw. <br />4 13. Told 14. Unit <br />vie 9uont' WtNol <br />i f I i/Ie-0 l�, <br />i I I f I <br />I I I 1 t <br />I I t f <br />IS. Special <br />Instructions and Additional Information <br />z 24 HR. EMERGENCY CONTACT: PRC 1-800-874-4444 <br />2 24 HR. EMERGENCY CONTACT: CHEM TEL INC. 1-800-255-3924 <br />c <br />APPROPRIATE PROTECTIVE CLOTHING & RESPIRATOR <br />J <br />Z16. GENERATORS cER11FICA7M: I hereby declare that the contents of this consignment are fully and accurate <br />Packed. marked. ab kabeled, and are n ala respects n proper condition for transport by highway aceo b above by doper �Png nate and are classified <br />If I am a sg to international and national regubtkxm <br />< large quantity generator. t certify that 1 have o program h Place to reduce the volume nriPy of wale <br />z all Plvctk;able OW#X* I have selected the and toxicity generated to the degree I have determined to be <br />practicable method of troafinent, storage. or disposal currently to me which nwtrraes the Present ant future wS threat 4o nsrnarn health and the ertvkonmett: pia. r 1 an o srnc1 quantity generator. I have made a <br />t good filth effort to rtninin2e my waste generation and select the best waste <br />s._ rtnonagernent method that b 40 me and that 1 can afford <br />J <br />Q Prhted/fyped Plane S Q<naturs <br />U <br />DO NOT WRITE BELOW THIS LINE. <br />0NS 8027A (12/90) <br />EPA 8700-22 <br />dem <br />12..1 IF -1 <br />Month Day year <br />MIN <br />White: TSOF SENDS THIS COPY TO DHS WITHIN 30 DA <br />To: P.O. Box 3000, Sacramento. CA 95812 <br />T <br />R <br />17. Trasporter 1 Acknowledgement wledgertent of Receipt d Materk <br />Pnhted/ryped Name SignatureU <br />N <br />w <br />Q <br />T <br />18. Tract er 2 Acknowte t of Rete' t of Material <br />Prirteollypedvane <br />Lu <br />E <br />Q <br />R <br />� <br />F <br />19. Discrepancy hdi=ion Spa® <br />Z <br />A <br />C <br />Lus <br />L <br />I <br />T <br />20. FacAitY Owner or Operator CeRAtcation of rece mofenCh covered by ft rt <br />Prknted/Typed Name <br />Y <br />Signahre <br />G$`LQ:T-A <br />DO NOT WRITE BELOW THIS LINE. <br />0NS 8027A (12/90) <br />EPA 8700-22 <br />dem <br />12..1 IF -1 <br />Month Day year <br />MIN <br />White: TSOF SENDS THIS COPY TO DHS WITHIN 30 DA <br />To: P.O. Box 3000, Sacramento. CA 95812 <br />