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State of California—Health and Welfare Agency • • Department of Health Services <br /> Toxic Substances Control Division <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUSGenerator's US EPA 10 No. Manifest age n ormation in the shaded areas <br /> WASTE MANIFEST C.n. J (J I 1 5 `J. y 3 Docu�n tNo. of ' is not required by Federal <br /> 7 ! law. <br /> 3. eneratgr s Name and Mailing Address A'Sto/{�e z,I�A Ment Number <br /> J. <br /> ( <br /> 7 <br /> n <br /> .,. ;��:� � {J B. tateGenerator's I <br /> 4. Generator's Phone ( ori I .73 J L 7G <br /> b. Iranspofter 1 Company Name 6. US EPA ID Number C.State Transporter•s <br /> J rLruL�.cy, <br /> 0 <br /> JPhone rtp <br /> ransporter .J o2 y <br /> Company Name US EPA ID Number E. tate ransporter's ID <br /> ETransporter's..,P.hone- <br /> 9. Designated Facility Name and Site Address OS EPA ID Number I G.Stats Facility's ID /' �/ <br /> 46 c.,,e, 7 OOIP Yt�- II', <br /> ihtys hone <br /> tr, 7-1 ,r / y �2 <br /> 12.Contamers 13. 14. <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class, and ID Number) Total Unit Waste No. <br /> No. Type Quantity <br /> G <br /> e a 1-IPZ1;-tiw.5 C�F,5 JC... �y.IC iQ 1 f/ <br /> R <br /> E /v,0 U�Z nI � `. i/.�' q /r� h�IVl r 1/ �. / <br /> A b. <br /> T <br /> 0 <br /> R <br /> C. <br /> d <br /> J."';A�ditlonel Description Y Materials Usfed K.Hendling Codes for Wastes Listed Above <br /> 0, c5 e i <br /> � .0 0 <br /> x <br /> 16.Special Handling InstruCtions and Additional Information <br /> 16.G EN ERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and we in all respects in proper condition for <br /> transport by highway according to applicable international and national governmental regulations. <br /> Date <br /> Printed/Typed Name .. Sigynatu�re I Month Day Year <br /> C <br /> T 17,Transporter 1 Acknowledgement ofReceiptof Materials Date <br /> R Printed/ yped Name Signpture Month Day Year <br /> 0 18.Transporter 2 Acknowledgement or Receipt of Materials Date <br /> R Printed/Typed Name Signature tM.-1hLLYajr <br /> E <br /> R <br /> 19.Discrepancy Indication.Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> T20, Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> y Item 19. -Date <br /> _. <br /> Prined Name Ignetumonth Dey Year <br /> .,? J2 <br /> DHS 8022 A(7/84) <br /> (EPA 8700-22) Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS 84 '1 <br />