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� T „ <br /> Department of Health Services <br /> W <br />" Z11t taof Callforn(a—Health and Welfare Agency Toxic Substances Control Division <br /> b ` <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> t4. <br /> NIFORM HAZARDOUS enerators o. Manifest age normationinthe shaded areas <br /> Document No. of is not required by Federal <br /> WASTE MANIFEST 1 Is <br /> nerator s Name and Mailing Address A t nifest oc ment Number <br /> alifornia Dept. of Transportation <br /> .O. Box 2048 S. tate Generator's I <br /> tockton, CA201 CAD981158983 <br /> nerator's Phone ( 2 ) 948�-7808nsporrer Company Name US EPA ID Number tate. ransporter's ID .� <br /> '.t,. Chemical Waste Management �Wcj CAD0.03986.718. D. ransponer's Phon <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. tate ransporter's ILY <br /> . . . . . . . . . . ransporters Phone._ <br /> Designated Facility Name and to Address 10. US EPA lD dumber GState Facility's'-ID <br /> Chemical Waste Mgookm Inc. , Kettleman Hills Facility. ,: <br /> 35251 Old Skyline Rd. acl Itys. Phonw' I <br /> Kettleman City, CA 93239 <br /> AT000646.117• � 209-386-9711 <br /> 12.Containers 13. 14. 'a.I <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class, and 1D Number Totai Unit Waste Na. <br /> a No. T e Ouanti <br /> e a. <br /> N <br /> t Hazardous Waste Solid N.O.S. ORM_B NA9189 001 DT uo Y 611 <br /> R <br /> A b. <br /> T <br /> o <br /> C. <br /> d. _ ;y <br /> -W total' <br /> .tt+ ipti..o�n{sYr.;or:r+ atsweemri.a-�l.s..t List.adw E ,^�� R,a 'w^�y. <br /> Handling Ces forWastes st 71 <br /> wJHdrQcaaminated $ <br /> y <br /> SM:y• r_ .s' ,x �^. <br /> 15..Special andling nstructians and tiditional n ormatron <br /> 4 <br /> ENVir0,,-V,,,iTAL HEALTH <br /> :I hereby declare that the contents of this consignmem are fullyand 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 re Mations. <br /> Date <br /> Printrpm- ame Signator Month Day Year <br /> T 17.Trans r 1 Acknowledgement of Receipt of Materials Date <br /> R <br /> A Fir Name Signator Month Day Year <br /> N o <br /> s ,4 0' ! �/ Q <br /> P <br /> 0 18.Transporter 2 Acknowledgibment oV Receipt of Materials Date <br /> R <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> 19,Discrepancy Indication.Space <br /> F <br /> A <br /> C <br /> f <br /> L <br /> T20.Facility Owner or Operator; Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T Item 9. <br /> Date <br /> Tint 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 8700-22) 84 8%41 <br />