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Califamia—HaaWi ^'and Welfare Ayoncy ❑apartment of Health Services <br /> Toxic Substances Control Division <br /> j Sacramento,Callfornla <br /> Please print or type., (Form designed for use on elite(iF-pitch),typewriter,) <br /> i <br /> UNIFORM HAZARDOUS70"D2.gJ15nerators o. aniest age normationintheshadedareas <br /> �t WA,�,TE MANIFEST43't�lo. of �aWnot required by Federal <br /> ,t;, enerator s ame and - ailing Address Adlj �n e ment Number <br /> Cali;ornia Dept. of Transportation � . <br /> s <br /> P.O..- BOX 2048 .. 8, tateGenerator's ID., <br /> StO kton, CA241 "'=r CAD9811S8983 <br /> 4; Gen'erator's Phone { 2 f 9 4$—7 8 $ <br /> rarIls=orwr ompany Name 6. US EPA 10 Number , tate ransporter's_ ID <br /> r <br /> •., `Cliemical Waste Management_rn�_ CAD003986718. . . ransporters Phone <br /> rFnspo_rt ar ompany ame 8. US EPA ID Number E.State ransporter's <br /> V-A a^A 0-F. ransporter s Phone-, .."; <br /> esignat <br /> Facility Name and ite Address 1 . US EPA ID Number tater acillty a ID Y <br /> Chemical Waste MqWM. Inc. , Rettleman Hills <br /> 35251 Old Skyline Rd _" � <br /> y actilty a Phone <br /> Kettleman City, CA 93239 209-386-97161 ' ' <br /> 12.Containers 13. 14. <br /> 11.US DOT Description(lncluding Proper Shipping Named Hazard Class, and ID Number) Total Unit Waste No. <br /> a No. T e ouantity <br /> E a. <br /> Hazardous Waste Solid N.O. S. ORM-E NP-9189 001 JDT <br /> r� <br /> ,A b <br /> r T <br /> R <br /> C. <br /> d. F, <br /> •.t IUt7l3e ortlt C!' met'lis 4'" ""~ „ K.Handung Codes for Wastes listed ve <br /> d�i7�F,. 1��s'�:�r' �-�"•��".'�=.''yS `'����"�'}�fin"' e ,, '"��7�(�� � <br /> qa bdn <br /> `1!'f-. "Y. r7L� •"a.. `�" "ijs ,L+a 'y r '� 3� r �y.•1j r r*4"r, �, 4v <br /> T•. .�,.�".Pi':'Y s,. �d'y;.: A. ,f,r• y`aY ,.Yp.i a.W"1 +t:-�" C'.v Y'.{.9 �.f7 ..5r J .a' � r, - <br /> 15. pecial Handling I nstr.c'Fions andAdditional n ormation _ <br /> LCJ4�; , •s ALTH <br /> "CLS <br /> A :Iherebydeciarethat the contents o this consig nm ent are f ullyand accuratelydescribed <br /> above by proper shipping name and are classified,packed,marked,and labele5L nd ata in all respects in proper condition for <br /> transport by highway according fo applicable international and national gover ental r lati . <br /> Crate <br /> Printed ame Sign Mont D y Y a <br /> 5,7x Cly c_ . �' l Mp <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R <br /> A Printed/T a 9 Sign cults Month Day Year <br /> N <br /> 0 18.Transporter 2 Acknowledgement or Receip of Materials' I+ Date <br /> R <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication.Space <br /> f <br /> A <br /> C <br /> I <br /> L <br /> i 20. Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T <br /> r Item i 9. <br /> Date <br /> tinted yped Name Signature Month Day Year <br /> Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> DHS 8022 A (7/84) To: P.O. Box 400, Sacramento, CA 95802 <br /> (EPA A 7oo-22) 94 M64t <br />