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i j Department of Health Services <br /> ■ <br /> State of Catltornla—Health and Welfare Agency Toxic Substance's Control plf s oa <br /> Sacramento.,California <br /> t <br /> A y <br /> oe"Olesse print or type. (Form designed for use on elite 112-pitch)typewriter-) Manifest age n orrnerian in the shaded areas <br /> UNIFORM HAZARDOUS enerator s °' Document No. is not required by Federal <br /> . . of law. <br /> WASTE MANIFEST t e A.Sta e M84560 <br /> nifest Document Number <br /> Generator's Name and Mailing Address fl <br /> California Deet. of Transportation B.State Gan�erjjataor's ID <br /> 34 <br /> P.O. Bay 2048 <br /> Stockton, CA„ 201 CAD181158983 <br /> 4. Generator's Phone ( c ) 948-7808 <br /> 5. ranspotser 1 Company Name US EPA ID Number C. tate Transporter's ID r� r. <br /> �.,' CAi��Q 3�,a 6718. D.Transporter's Phone <br /> Chemical Waste 3-lanagament -� <br /> 7. Transporter Company Name 8. US EPA ID Number E.State Transporter's <br /> Rr <br /> F.Transporter's Phone <br /> 9. Designated Facility Name and rte Address 10. US EPA ID Number G.State Facility's ID f . <br /> Chemical Waste tom: 1ric. , Kettleman hills Facility <br /> 35251 Old Skyline Rd. H. acility's Phone <br /> Kettleman CitY, ,CA 93239 _ <br /> rATQ0064AI 11 2612.Containers 1 14- 1 <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class, and ID Number Tot13al Unit Waste No- <br /> No. T e Quanti <br /> Cy <br /> E <br /> a. <br /> E FI a arclaus Waste to Solid Pa.O.S. OPM-Z NA9189 001 DT y 611 <br /> R <br /> A b <br /> T <br /> 4 <br /> R <br /> C <br /> d. <br /> J. Additional flescriptions for Materials Listed Above <br /> K.Handling Codes for Wastes Listed Above <br /> Soj.1 Contaminated ,tvf �Hydrocarbons <br /> W s�te' Prefile OSPO F2625] <br /> 15.Special Handling Instructions and Additional In ormation <br /> ENVIF' r0EJAL H-EALTH <br /> F F',13 I(SERVICES <br /> 16.GENERATOR'SERTIFICATI Pl:lherebydeciarethatthecontantsofthisconsignmeniare ullyandaccuratelydescribed <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 /> Month Day Year <br /> Printed/Typed,-Name <br /> Signature <br /> l r'�f r�l <br /> ,. ' Date <br /> T i7.Transporter 1 Acknowledgement of Receipt of Materials Month Day Year <br /> R Name Signature. <br /> H Prim ITYP� _!. � :� ,.; ,..fes- �• ,, <br /> Date <br /> 0 <br /> —i—S.Transporter 2 Acknowledgement or Receipt of Materials Month Day Year <br /> R Printed/Typed Name Signature <br /> e <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> L <br /> M 20.Facilityy Owner or Operator: Certification of receipt of hazardous materials covered by this manifest. except as note m <br /> Y Item 19- Date <br /> Printed/Typed Name <br /> Signature Month Day Year <br /> t i <br /> DHS s -2 c7r8a} Yellow- TSDF SENDS THIS COPY' TO GENERATOR WITHIN 3d DAYS 8"�"" <br /> TEPA 87070 0-22) <br />