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______ _ _ __________ <br /> State of Callfornla—Health and Welfare Agency • �'' ,1a Department of Health Services <br /> Toxic Substances Control Dlvlslon <br /> Sacramento,Callfornla <br /> Please print of type. (Form designed for use on elite(12-pitch)typewrites) <br /> UNIFORM HAZARDOUS 1 Generator's US EPA I D No. Manifest 2.PageI Information in the shaded areas <br /> WASTE MANIFEST p. Y _r.� Do,m(em No. of lawnot required by Federal <br /> Generator's3. Name and Mailing Address Alyl `� <br /> �ita LMa2nttsstL Documentlli <br /> � Num <br /> Fl L i J'r ",A 7- C� T�Rv.`y <br /> /G J6 /' C (, �,� �</ G-/`t J tate Generator a1 <br /> U < <br /> 4. GenerArg) hone j <br /> 5. Transporter 1 Company Name 9.0 US EPA ID Number tate ransporter's 1 <br /> ransporter s. hone. <br /> a. <br /> 7. ransporter 2 Company Name US EPA ID Number E. tate ransporter's ID." <br /> F. ransporters Phone'- <br /> 9. Designated Facility Name and Site Address 1 US EPA ID Number G.StateFacility's ID <br /> (-.<75 1C' nn nM�6e,r-„r �l <br /> a] S"e/II'-C &0ID H.Fa 11i s hone . _ <br /> C.A. f.r, . ; ; r. A <br /> 12.Containers 13. 14. 1 <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class, and ID Number Total Unit Waste N0. <br /> No. Type Quandt <br /> 0 <br /> E <br /> a Ij�L <br /> E A e' .$ . O rC N'+ - rv.^, J 9 Cz'll pT .I •` ' ! '�/ I ,''! "'> <br /> R <br /> A b. r <br /> T <br /> O <br /> R <br /> C. <br /> d. <br /> }' <br /> Nona • i 'on 11 r,. pian s List Above t K.Handling Codes—for Wastes Iste ve <br /> '',�,• 4: -.:x* ,, 'r�!. s ': IC.A `_i Vii. . d D - flrtr, `, <br /> t. n pf G',jl' J <br /> 4'al��'i""{�J 24t tAL�. `�/ � u,/•i 1 / (moi <br /> ,f <br /> Special16. andling Instructions and Additional Information <br /> RTIION:Iherebydeclerethat the contents of this consignment are fully and accurately described <br /> above by proper shipping name and are cessified,packed,marked,and labeled,and are in all respects,in proper condition for <br /> transport by highway according to applicaale international and national governmental regulations. <br /> Date <br /> Primed/Typed Name Signature Month Day Year <br /> \44 t <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R Printed/Typed flame ice, Sign�ure � / � Monrn Day Year <br /> 0 1 ransporter 2 Acknow edgement or Recei t of Materials - Date <br /> T 7nmed/Typed Name j Signature month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication.Space r <br /> F <br /> A <br /> C <br /> 1 r <br /> L <br /> 20.Facilit Owner or Operator: Certification of receipt of hazardous materials covered by thisnifest except noted in <br /> T <br /> Item �9. Date <br /> Printed/Typed Name ignature _ j Month Day Year <br /> DHS 9 A(7/84) Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS t <br /> TEPA 87070 0-22) <br />