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Z5 0-At <br /> State of California—Health and welfare Agency Department of Health Services <br /> Toxic Substanc*rer=CgLZUWAjon <br /> CJ !� Sacramento,California <br /> Please print or type. (Form deigned for use on aloe(12-pitch)typewriter 1 <br /> UNIFORM HAZARDOUS 1.Uenerator's US EPA iD No. Manifest 2.Page I Information in the shaded areas <br /> WASTE MANIFEST .A7(000 au�f �S SlO Document No. of lawnot required by Federal <br /> 3. rarator a Name anq ailing Address A.State Manifest Document Number <br /> carrCh0tA C& . 84168075` <br /> Rolc sea- <br /> ` $tcicktD.1 CH 4�a0 '� 9. tate eneretora <br /> 4. Generator's Phone 1 <br /> ransporser I Company Name US EPA ID Number C.State ransporter's ID15 <br /> .Z / Y9( ! D. rensporter's Phone � MDQ <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. tate Transporters ID <br /> . . . . . . F. ransporter's Phone <br /> Designated Facility Name and Site Address 10. US EPA ID Number G. tate Facility's ID <br /> z'T cOt-�' F C,A()Gbo g0-77/ <br /> Fujin ttldrerbi�tJ I�C� acilirys Phone <br /> mist-t-tneZ f CIa �1�5's�3 L'ia.lJ(JD D D 9Y�r7/ t-4/!57— 22$- SIOD <br /> 12.Contamers 13. 14. 1 _ <br /> 11.US DOT Description(including Proper Shipping Name,Hazard Class, and ID Number Total Unit Waste No. <br /> d No. Type Ot anti <br /> E <br /> N . r <br /> 1i$ul d C ; ( /9i3 00.1 �T /o X06 G <br /> �r a ` <br /> A b. <br /> T <br /> 0 <br /> p <br /> C. <br /> d. <br /> ` J. Additional De=iptions for Materials Listed Above K.Handling Codes for Wastes Listed Above <br /> Sex— 19-71-7fS '7,3'70 w A-5 llzo l <br /> 15.Spedal handling Instructions and Additional Information Q / ' /_• <br /> �-zvrn £P,a t <br /> ran-nom -z r c,,,16.GEN t <br /> ERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and are in all respects in proper condition for <br /> transport by highway according to applicable international and national governmental regulations. <br /> fo I Date <br /> Printed/Typed Name Signatur Month Day Yeer <br /> U" Su zv,�P T S fah r�,a -� z-f( �Y 07 s' <br /> R 17.Transporter 1 Acknowledgement of Receipt of Materials ✓ Date <br /> Printed/Typed Name Signature Month Day Year <br /> Ria Z�t=(3 /y / (/ 08 <br /> 1 CITIES- <br /> n 18.Transporter 2 Acknowledgement or Receipt of Materials V v Dale <br /> II T Printed/Typed Name Signature Month Day Year <br /> V, a <br /> R <br /> 19.Discrepancy Indication Space e(Y�G.t .-� c <br /> ('t (S (' ni nc� � `/, mac..\c_ u� 0 10 , pc�reck.,Fr� <br /> IF <br /> JOY, u00�h u Lt�e g V. 61 k �,s Pc>r <br /> -j 1r � f - <br /> t 20.Fecibty Ownor or Operator: Cnndiceuon of receipt of hazardous materials covered by this manifest except as noted in <br /> T Item y9. <br /> T i�— pate _ <br /> tinted <br /> yped Nnme bignature Wanrn aar /eM <br /> l / <br /> ( � f' 1. _l I li`•( 1 � I ;/��. I l r 1 � '/�l 1 l' � � ! t'k ^• /"• , �, l , 1 I\ `v- , <br /> DHS 8022 A(7/e4) -• '). .Jox ,1UUU, '..,iuu mP•mpr, <br /> (EPA 0 100.22) Marr <br />