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• of Calliornla—Health and Welfare Agency Department of Health Services <br /> Toxic Substances Control Division <br /> Sacramento,California <br /> r216ase prim or type. (Form designed for use on elite It 2-yilch)typewritacl <br /> UNIFORM HAZARDOUS Uenerators o. Manifest age Information in the shaded areas <br /> _ Document No. is not required by Federal <br /> WASTE MANIFEST a f �' r ? r r of <br /> aw. <br /> Generator's Name and Mailing Address T.Stk%e Manifest Dpcument Number <br /> .v, 4 lie F.. C) 71,19 <br /> B State Generator's ID <br /> 4. GendratoA' Phone 1 - 1 �' '=� ' I - <br /> 5. ransporter ompanyN me US EPA ID Number tate Trensporter's ID <br /> r „ f 4 `, t-.. ,." .y. D.Transporter's Phone24 1 <br /> ransporter Company Name US EPA ID Number E. tate transporter's ID <br /> . . . - .Transporter's Phone <br /> 1 y,Designated Facility Name and Site Address 10. US EPA 10 Number G.State <br /> as rC A„q.:a{,c ��T ( 1� ✓�77(7�� <br /> H.F cility'qa Phone <br /> r _ + 12.Contam s 3. 14. I, <br /> i 1.US DOT Description(Including Proper Shipping Name,Hazard Class, and ID Number Total Unit Waste No. <br /> No. T e Quantity <br /> if <br /> iN <br /> A <br /> ! T rb <br /> ° i <br /> I C. <br /> I <br /> i <br /> L__ <br /> d. <br /> — <br /> Additional Descriptions for Materials Listled� _ :Handling Codes for Wastes Listed Bove <br /> e CL <br /> 0 IC C'0,V 7-'/0, ,. ' 5 <br /> ;fro l Liz, <br /> 1 pedal Handling Instructions and dditional n ormahon <br /> II a <br /> nd accurate) described <br /> d <br /> SII IaretNat the contents of this consi nmerY.ere u y Y <br /> 1 GENERATOR'S CER IFICATI N.I hereby dec 9 <br /> above by proper shipping name and are classified,pack`ej'msrked,and labeled,and mein all respects in proper condition for <br /> i transport by highway according to applicable international and national governmental regulations. <br /> Date <br /> Printed/Typed Name Signature Month Day Year <br /> i T 17.Transportir 1 Acknowledgement of Receipt of Materials - Date <br /> A Printed/Typed Name Signature Month Day Year <br /> N, <br /> a - Date <br /> 18.Transporter 2 Acknowledgement or Receipt of Materiels <br /> Printed/Typed Name Signature Month Day Year <br /> 19.Discrepancy Indication Space - <br /> � I <br /> I <br /> 20.Facilityy Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> Item 19. Date <br /> Printed yped Nime �- y�� Signature �•- I I Mo!tthh Day lrz �Y.eaar <br /> ti; <br /> DHS 6022 A(7/84) awl <br /> cPA 6700-22) <br />