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Department of Health Services <br /> State cj Californias—Health and Welfare Agency �• Toxic Surstance$Control Division <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter,) an+ est . age In ormation in the shaded areas <br /> enerator s <br /> UNIFORM HAZARDOUS -OTEPA1 "VADqR1151284 <br /> o Doctfinent No. of iaswnot required by Federa <br /> WASTE MANIFESTA t nlfe t ocument Number <br /> enerator s Name and Mailing Address ¢�j <br /> California inept:. of Transportation U <br /> P i G� Bax 2048 B.State Generator's ID <br /> ` Stockton, CA 201 CAD981158983 <br /> 4, Generator's Phone { } 94 6.8-7808 US EPA 10 Number C.State Transporter's ID , <br /> 5. Transporser 1 Company Name <br /> Chemical Yeas to Manage �+- CADf?039867tE� D.Transporter's Phone <br /> . Transporter Company Name B. US EPA ID Number E-State Transporters <br /> F.7ransporta, s Phone <br /> Designated Facility Name and ite Address 10. US EPA ID Number G.State Facility's ID <br /> Chemical Waste Imo: Inc. , Xpettlerlan Hills Facil ty <br /> 35251 Old Skyline Rd. R.Facility's Phone _ <br /> Kett.leman City, CA 932:39 117. <br /> 12.Containers 13. —14- { <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class, and ID Number Tota! Unit Waste No. <br /> No. T e Quanti d <br /> G <br /> E a• '- y 'p <br /> E Hazardous Waste Solid �`-0-S- C4R�"�,.•E N�79189 001 DT � � 4J <br /> R <br /> A b. <br /> T <br /> 0 <br /> R <br /> C. <br /> d. <br /> 7ng Codes for Wastes Listed bove <br /> J. Addiaonat DescriPt+ons� r Meteriais Listed Attove v, <br /> r <br /> 5 :3 Gv'nti ated W/ Hydrocarbon s �. � <br /> pecial Handling Instructions and Additional In ormation ;lEALTH <br /> F ERMIT/SERVICES <br /> 1 .CyEhIE AT P.'S ERTIFIOATI N:Iherebydeclarothat the contents ofthisconsignmereare ull(andaccuratetydescribed <br /> above by proper shipping nameand areclassified,packed,marked,and labeled,and grain rail respects in proper condition for <br /> transport by highway according 10 applicable international and national governmental regulations. Date <br /> / <br /> Si Hato Mont Day, Year <br /> Printed/? Name f {I <br /> 1 G g — <br /> Rate <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Month Day Year <br /> A Printed/Typed Name _Ln.—ature <br /> N Date <br /> 0 18.Transporter 2 Acknowledgement or Receipt of Materials' Month Day Year <br /> R Name Signature <br /> T Printed/Typed <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L red by this manifest except as note <br /> t 20.Facility Owner or Operator: Certification of receipt of hazardous materials covem <br /> T <br /> item 19. Date <br /> Y Month Day Year <br /> Printed/Typed Name Signature <br /> DHS 8022 A (7/84) 84 8D641(EPA 8700-22) Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />