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Department of Health Services <br /> State cf California—Health and Welfare Agency i Toxic Substances Control plvlslon <br /> Sacramento,Callfornia <br /> y � <br /> Please print or type. (Form designed far use on elite S12-pitch]typewriter.] ani est age 1 In ormation in the shaded areas <br /> enerator s o. <br /> UNIFORM HAZARDOUS Document No. Is not required by Federal <br /> WASTE MJ,p►hIIFI=ST ,< .�. ., _. � of law. <br /> A t e n fes merit Number <br /> Generator'sName and Mailing Address t 2 <br /> A Cajil ornia Dept. of iranzportat l on <br /> f3.State Generator's 10 <br /> P.O. Box 2048 <br /> tockton CA 201 CAD981158983 <br /> 4. generator's PhJne f 2 1 948-7808 <br /> 5. ranspoAer 1 Company Name b. EPA ID Number C.State Transpoiter's ID <br /> chemical Waste Mana� ���(�3 9Z G 71 G. . . D.Transporter's Phone <br /> lnq-qlq 2076 <br /> Terjnn t: <br /> 7. <br /> ransparterz Company Name 8, Us EP,4 ID Number Ir.State Transporter's <br /> F.Transporter's Phone <br /> 9. Designated Facility Name and Site iAddress r 10. US EPA lD Number G. tate Facility ID <br /> Chemical Waste %3 . inc- , Kettieman dills >racil ty 0�, cy <br /> 35251 Old Skyline Rei. _Facility's phone <br /> Kettlermn City, CA 93239 --g 6117. . . . 209-386-9711 <br /> 12.Containers 13, 14. I <br /> 11.US DOT Description(including Proper Shipping Name, Hazard Class, and ID Number Na.t <br /> QTot it Unid Waste No_ <br /> G <br /> e a. <br /> E Hazardous Wazte Solid N.O.S. CM-�E NA9189 x}0. � 621 <br /> R <br /> A b. <br /> T <br /> o <br /> a <br /> C. <br /> d. <br /> J. Additional Descripuons or eterials Listed Above - <br /> K.Handling Codes for Vllastes Listed Above <br /> soil :-Contaminated w/ Hydrocarbons <br /> Waste Profile WO x'.26251ENViRVAIENTAL HEALTH <br /> FE AIT/SERVICES <br /> 16.-Special Handling Instructions and Additional Information <br /> 1 . EN A QR' CERTIFI ATI -Li- - Bbydisc arethatthecontentso thisconsignmerY..are ullyand 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. pate <br /> Printed/Typed Name Signature fl <br /> Month Day Year <br /> F2. 1' P e :u, Date <br /> T 17.Transporter 1 Acknowiedgement of Receipt of Materials r <br /> A PrintedlTyped Name Signature Month Day Year <br /> f I It <br /> s <br /> rDate <br /> 0 18.Transporter 2 Acknowledgement or Receipt of Materials <br /> T Month Day Year <br /> Printed/Typed Name Signature <br /> e <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> G <br /> I <br /> L <br /> i 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as note in <br /> T <br /> Y Item 19. spate <br /> Printed/Typed Name Signature Month Day Year <br /> (EP $70 -2 c�ie¢) Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS 84&9641 <br /> (EP87t7Q-22) <br />