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State of California—Health and Welfare Agency • • Department of Health Services <br /> Toxic Substances Control Division <br /> s Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest age n ormation in the shaded areas <br /> oc is not required by Federal <br /> WASTE MANIFEST C A D S 81 1 5 319 8 3 �3 nYnto. of law. <br /> Generator's Name and Mailing Address ' tate,Manifest..Document Number <br /> CA Dept. of Transportation '-f 314 z/ 10 <br /> 1976 Ee Charter Way, Stockton, CA 95201 B.StateGenerator's ID <br /> 4. Generator's Phone I 209 ) 935-2076 <br /> 5. ransporser ompany Name US EPA ID Number tate ransporter's ID If) Vill <br /> IqC I/f,$O /LOC/C " O O 4 ransporter's Phone r <br /> ransporter Company ame US EPA ID Number tate ransporter's ID <br /> F.Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G.StateFacility's ID <br /> Chem Waste Management �� <br /> 35251 Old Skyline Road . a ilitys hon, <br /> t <br /> 12.Containers 13. 14. <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class, and ID Number Total Unit Waste No. <br /> s No. Type Quantity <br /> E a. <br /> E Hazardous Waste Solid, N.O.S. , ORM-E, NA 9189 001 DT O f8 Y <br /> fl <br /> A b h <br /> T <br /> 0 <br /> fl <br /> 6. <br /> d. <br /> i4 <br /> J Additional om o[ aterials listed K.Handling Codes for.Wastes Isted ve <br /> � '`}+"'�i 'i� =y� }F" gni«,•y . <br /> So � ei �tl ,riesel t#uel+- Profile 4F26261 6?� <br /> 16. <br /> Special Handling Instructions and Additional n ormetlon <br /> 16.GENERATOR'S CERTIFICATION:I hereby declare thatthe contents of this consignment areTully and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and mein all respects in proper condition for <br /> transport by highway according to applicable international and national governmental regulations. <br /> Date <br /> Printed/Typed Name Signguue-t �-- Month Day Year <br /> T 17.Transporter!•1 Acknowledgement of Receipt of Materials Date <br /> A Printed/Typed Name Signature Month Day Year <br /> N, V, LLA (,' rL [ <br /> 0 18.Transporter 2 Acknowledgement or Receipt of Materials i - Date ` <br /> R - Month Da Year <br /> r Printed/Typed Name 15ignature Y <br /> E <br /> R <br /> 19. Discrepancy Indication.Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> T 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> y Item 19. Date <br /> __ Printed yped Nam Signat rMonth Day Year <br /> _ e— !!-, <br /> ? ?•- ,f <br /> DHS 8022 A(7/84) ✓ � - <br /> fEPA 8700-22) Yellow: TSDF SENDS THIS COPY TO GENERATOR (THIN 30 DAYS 811 8116,1 <br />