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State,or California—Health and Welfare Agency • Department of Health Derision <br /> Toxic Substances Control Division <br /> Sacramento,California <br /> Please print or jype. ' (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS Generator's o. —Manifest age s not requir requiredbyFedeed ral <br /> WASTE MANIFEST <br /> ID U41%. of j lawnot requved by Federal <br /> enerators ame end Mailing Address A tate.:��nnaa��nl£gg npp�q ment• Number, <br /> CAt , �rnrP pec' ]'f 14-sIot/ 7-,9- rn / 456f.? 69 , <br /> y�� C 4' - T�/ Z t;16•,- tete Generator's <br /> ID <br /> 4. Generat�'s Phone(a O r Ij 5 20 747 <br /> ranspotN ompany ame US EPA ID Number tate ransporter's ID 0 <br /> D. ransporter'a hone y 263'SL y <br /> r � t <br /> rensporter pany Name US EPA ID Number tete Transporlu <br /> ter <br /> F.T ranspo ter's-- hone9. . <br /> Designated Facility Name and Site Address 10. US EPA ID Number G. tate ,Faccilliity's ID <br /> Ci emlCNl (�. F$7C ! /? ?LC t vT 6671 6CCYo I/ <br /> aci tty s one <br /> eery l � r� C Tj , 1235 C. 4. rU.o. a. Gy. 6. . 1 . 7 56 -21/ <br /> 12.Containers 13. 14. I <br /> 11.US DOT Description(including Proper Shipping Name, Hazard Class, and 10 Number) Total Unit Waste N0. <br /> No. T e Quantity <br /> G /-)r- / y /, <br /> N Olt <br /> (� .�. f.. 81 <br /> 1/ N�f V�J <br /> R N O 5 Ori M — 1` ^J,n j /�5 1 <br /> A b, y <br /> Tc- <br /> O <br /> R FV. <br /> C. <br /> d. f <br /> J *At]tlal iptionsy 0 etermk Ust... ,.,.... .. _ K.Handling Codes for Westas Isted ve , <br /> (..p.t � O,CSe / /n <br /> pecla an hng nstructlons and AdditionaF Informiti—on <br /> GENERATOR'S16. CERTIFICATION:I hereby declarethat the contents of this consignment ere ully and accuratelydescribed <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. Date <br /> Printed/Typed Name Signature Month Day Year <br /> z... : t E tom ,:, ca l <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R Month Day Year <br /> A Printed/Typed 7a `" Signatu� / <br /> Na �j�` { /� .1 F C L ! T'f C 1 r /f c C- lr ' C'Z <br /> P Date <br /> 0 18.Transporter 2 Acknowledgement. Receipt of Materials <br /> RSignature Monrn Day Year <br /> T Printed/Typed Name <br /> R j <br /> R <br /> 19.Discrepancy Indication.Space <br /> F <br /> A <br /> C <br /> t <br /> I 20.Facility Owner or Operator: Certification, receipt of hazardous materials covered by this manifgst. x pt as noted in <br /> T Item 9. Date <br /> r MV OD Y <br /> 'nted ype¢ Name Signature <br /> g A(7/84) 84 ON41 <br /> Q-22) Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />