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State of California—Healtrland Welfare Agency • • Department of Health Services <br /> To Substances Control Division <br /> Sacramento,California <br /> Please print or type, <(Form designed for use on elite 02-pitch)typewriter.) <br /> U (FORM HAZARDOUS enerators o. Manifest . age normationinthe shaded areas <br /> Document Noof is not required by Federal <br /> WASTE MANIFEST A ( r ! T• ! aw. <br /> 3. Generator's Name and Mailing Address AState.,Mande§t„.P ant Number <br /> Cf-') L fit, F.v , /.' f''r o/ fir .v fr,� _ � � >;J ws^9 ..) ++.� <br /> B. tateGenerator's ID <br /> i <br /> 4. Geneieto `s�hone 1 1 5 o r <br /> 5. ranspgA@r Company ame US EPA ID Number tate ransporter's ID <br /> _ �., .�. ransportat's hone <br /> ransp rte dmo any Name ~US"E A I umber tate ransporter's in I <br /> F- ransporter'a Phone. <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G.StateFacility's:ID <br /> 5 1 D: O '' !I acility s one _ <br /> -•. .G 'r 4'Y O'l7. �. .1 t,.O "{ / � <br /> 12.Containers" 1 4. 1 <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class. and ID Number Total Unit Waste No' <br /> No. Type Quantity <br /> 0 <br /> E 8. L ,41 Z 1- <br /> N f' 1"�)GlS Cw.,In S TC- <br /> E ooi <br /> A b. <br /> T <br /> 0 <br /> R <br /> C. <br /> d <br /> J�Ll itionsl Descriptions,, or ate isle Usted Above K,Handling Codes for Wastes UstAbove <br /> rh'-qif-1'7 4j, h- —0itfSCl <br /> 0-3 <br /> �:. <br /> pecde andling nstruadonsand Acklitioral Information <br /> RTI FICATI 0 N:I hereby declare that the contents ofthisconsignmer%are ully and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and aro in all respects i n proper condition for <br /> transport by highway according to applicable international and national governments)regulations. Month Day Year <br /> Date <br /> Signature Printed/Typed Name g, \;� � ` � ! <br /> ( x +12... � � - , <br /> 7-1 <br /> r 17. ransporter 1 Acknowledgement of Receipt of Materiels , \ Date <br /> qMonth Day Year <br /> A Printed/Typed Name Signature ��. <br /> �. <br /> At <br /> 0 18.Transporter 2 cknowledgement ci Receipt of Materials' Date <br /> R Printed/Typed Name Signature Monrh Day reef <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 es{Fept as noted in <br /> T <br /> Item 9., Date <br /> Printed/Typed Na,i�"a / / - I Signature _.� Month Day ar <br /> DHS 8022 A(7/84) Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> (EPA 8700-22) <br />