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State of Callfornla—Health and Welfare Agency Department of Health Services <br /> Toxic Substances Control Division <br /> _ Sacramento,California <br /> Please print w type. (Fwm designed for use on elite(. ichl typewriter.) <br /> U!�lIFORM HAZARDOUS Generator's o. and est2. age Information in the shaded areas <br /> HASTE MANIFEST Document No. of L. <br /> not required by Federal <br /> G 5404 law <br /> Generator s ams en ailing Address tate Manifest Document Number <br /> Escaion Unified School District 84307614 <br /> 1520 Yosemite Avenue 11.3tate Generator,s ID <br /> 4. Generr6rWT—TIC 532p <br /> renaporMr mpa ameU EPA ID Number _ <br /> a <br /> t rensporters hone <br /> 1. ransporter AgM ame 1I. US EPA ID Number <br /> tats ransporter's <br /> F. ransporters one <br /> 9. Designated <br /> Facility Name end ite ddress US EPA ID Number G.Start, Facility's ID - <br /> Bay Area Environmental <br /> 1125 Hensley5 H.Ile$psh,!fa�g <br /> 11.US DOT Description(lnc/tiding Proper Shipping Name,Hazard Class, and ID Number 12.Containers 13. ty 14. 1 <br /> Total Unit Waste No. <br /> No. <br /> a T Ouanti <br /> E a. <br /> E Hazardous Haste Solid NOS ORM-A UN 9189 002 OM 1000 P Ca only <br /> e <br /> A b <br /> T <br /> 0 Hazardous Waste Solid NOS DRM4 UN 9189 001 ON 500 P Ca only .- <br /> e <br /> C. <br /> d. z-.. <br /> J- -Aciftignall Vjjj- <br /> liptions for Materialist, - - - - r-Handling Codes for Wastes Usted <br /> A Diesel tless`LAan 1% B-Gas less than 1% <br /> r`? :Sand 99,1:0 1001+ Water S to toS <br /> Solid 0 sorb Solid o sorb 90 to 951: <br /> CAC 000015404CAC QO5412 <br /> pesaanciling instructions en dditional n ormation <br /> CERTIFICATION: OOJ <br /> 16.GEN EFIATOR'S 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 mein all respects in proper condition for <br /> transport by highway according 10 applicable international and national governmental regulations, <br /> % Date <br /> Printed/Typed Name Signature Month Day Year <br /> Mark H - /� p <br /> T <br /> 17.Transporter 1 Acknowledgement of Receipt of Materials ! Date <br /> A Printed/Typed Name Signature Month Day Year <br /> s <br /> F <br /> 0 18.Transpo A k ant or Receipt of Materials <br /> a <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> A <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> L <br /> 1 20.Facility Ow <br /> v nor or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T Item 19. <br /> Dets <br /> Printed/Typed ame Signature Month Day Year <br /> OHS eozz A(7/84) Green: HAULER RETAINS <br /> (EPA 8700.22) N Bg611 <br />