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zuastaneast umrvo u-31-1 <br />,.4 Sacramento,Calltornla <br /> Flease grin`or type. {Form designed for use on elit itch)typewriter.) <br /> UNIFORM HAZARDOUS Generator's o. Manifest ageInformationintheshadedareas <br /> WASTE MANIFEST CAD9-81158983. . . . Document No. of 1 iawnot required try Federal <br /> 3. enerator s ame and Mailing Addresst n e meet Number <br /> California Dept. of Transportation , <br /> P.O. BOX 2048 B. tate Generator's ID <br /> Stockton, CA =981158983 ' <br /> 4. Generator's Phone ( 28;2')1948-7808 <br /> 5. ransponer Company me US EPA ID Number tate ransporter's.!D :Z. 3 <br /> Chemical. Waste Management=,f/C CAD003986718. . . . ransponer's.Phone <br /> 7. Transporter 2 Company Name 8. US EPA ID Number tate ransporter's ID <br /> . . . . . . . . . . ransporter s Phone,...-'- > <br /> . Designated Facility Name an ite Address 10. U5 EPA ID Number tate Facility's..ID <br /> Chemical Waste tom. Inc. , -Kettleman Hills Facility <br /> 35251 Old Skyline Rd. acility'a Phone <br /> Kettleman City, CA 93239 EAfi000646117 209-386-9711 } <br /> 12.Containers 13. 14. <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class, and ID Number) Total Unit , <br /> a <br /> No. I Type Quanti ,Haste No. <br /> a. <br /> E Hazardous Waste Solid N.O.S. ORM-E NA9189 00.1 DT .. X11 <br /> R <br /> A b ; <br /> T <br /> 0 <br /> R .. <br /> C. <br /> d. r Y <br /> .L onef- atn to sterraK,Handling Codes for wastes lrstad ve <br /> " �_ <br /> SO� orttam�matec xw Hydrocarbon. . <br /> f�« r a a <br /> sa y �-.sog, f + <br /> w . <br /> X, 25 <br /> ' www <br /> e ��'k ��r �,�a�,5a,� , ,,�'F,�• r�'�,�`��,,{iq J� � mgt - '�' �i-S�` 1 rte- � 'k$�',^ �""�,..�- - <br /> Special 'Handling. nstructions an itiona n ormatlon <br /> w <br /> 16.GENERATOR'S <br /> CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurataHydescribed <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 jo applicable international and national governmental regulations. <br /> Dale <br /> Print rT N me Signstur Month Day "r r <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R <br /> A Printed/Typed Name Signature Month Day Year <br /> N / <br /> s <br /> P <br /> 0 18.Transporter 2 Acknowledgement or Receipt of Materials' Date <br /> R <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> p <br /> A <br /> c <br /> I <br /> L <br /> 1 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T <br /> r Item 19. <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 /> 1EPA 8700.22) 8d M641 <br />