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state of Cal ltorn la—Health antl 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 /> UJVIFORMHAZARDOUS enerators o. anleSst age normationinthe shaded areas <br /> WASTE MANIFEST A D 9' r5'J J S `I /1 o`�m nS 7 of l lawnot required by Federal <br /> enerstor a Name and Mailing pAddress 6 A.�tare�M l eegS,��0 maps Number <br /> I11 Jtri. L.. '�:� ! i�s� tate Generator's I <br /> %U C TO',, /y i C 1 <br /> 4. Generator's Phone ( 269 ) ! 35 --20 -2 6 <br /> b. liansponer 1 Company Name 6. US EPA ID Number tateransporter's ID 7 0 3 <br /> 4) (- ✓f$C �G C /G G r9 X 0 0 0 a / O rensportar's Phone Al OF <br /> 7. Transporter 2 Company Name US EPA ID Number It.5tate ransporter s"ID <br /> . . . . . . . . .. ransperrters, hone-:• �.: <br /> 9. Designated Facility Name and Site Address 1U. US EPA ID Number G.State aciliry's ID <br /> `,.�c.-�. ICF)C G'i'a1�G /" �^„ai6Cntc�.r �lrfTQC7�7fO��l� <br /> C <br /> 12.CoContainers 13. 14. 711I <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class. and ID Number Total Unit Waste No. <br /> No. Type Quantic <br /> G <br /> a. H �?t r ,00„.3 c"C? Olt <br /> E ria <br /> R <br /> A b. <br /> T <br /> 0 <br /> R <br /> C. <br /> d. <br /> 4 I one 'one= or. etartele Listed Afwva K,Handling Codes for Wastes SI Above <br /> K <br /> �/ t v Kf &I !�„ IG5CL <br /> . pecla an hng nstructiona and Additional Information . <br /> GENERATOR'S16. R A :I hereby declarethatthe cogterits of thisconsignment 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 4 NamSignatureSignature Month Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> A Printed/Typed a Si nature Month Day Year <br /> is <br /> 0 18.Transporter 2 Acknowledgement or Receipt of Materials _ Date <br /> T Printed/Typed Name Signature - Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication.Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 20.Facilityy Owner or Operator: Certification of receipt of hazardous materiels covered by this manifQSt except as noted in <br /> T Item 19. -Date <br /> Mon Da Yea <br /> inted ypad Name <br /> Signal in Y <br /> s 110014:: <br /> DHS 8022 A(7/84) <br /> (EPA 8700-22) Yellow: TSDF SENDS THIS COPY TO GEN ATOR WITHIN 30 DAYS 04 awl <br /> 0.• <br />