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••�� Sacramento, California <br /> f ties►prim or type. (Form dasignod for usa on Tits(1 2-Oitchl typawrItw <br /> UNIFORM HAZARDOUS enorator US EPA M No. aruesz 2.Page I Informationinthe shaded areas <br /> Document No, is not required by Federal <br /> WAS E MANIFEST of law. <br /> 3. •narators Name arlid Mailing ArIllresst n� a of mene Number <br /> California Dept, of Transportation , r <br /> P.O. Box 2048 <br /> Stockton, CA 95201 ELSface. .n.ratnrs. �. ;`Y .'f:,•4T <br /> 4. Generator's Phone ( 209 948-7808 CAD9811589835. <br /> ransponer r C=p4inyNam* 6. US EPA 10 Number tats!_ ransporter s. <br /> '*- Chemical Waste Management _, C CADCL03986i718. . . . rsnsponers. ,- <br /> ransporter 2 CompanyNam* 8. US EPA ID Number tate. ransportar s <br /> F. ranspoi ur s, <br /> 9. Designated acitry ama and to Addrosai 10. US EPA ID Number G.Surte, as lty st L�s r- _ <br /> Chemical Waste M, Inc. , Kettleman Hills Facia ' t `i..t; �t:t A;;: <br /> 35251 Old Skyline Rd. actltYa_' n« .R <br /> Rettleaman City, CA 93239 <br /> G 054 117. -209-386-9711 �- <br /> 12.Containers 13, 14. <br /> 11.US DOT Description PrWuding Propar Shipping Name, Hazard Class. and 1D NNmbar) Total Unit <br /> o No. Type QuantiLf <br /> Waste Na_...,} <br /> r SaZardaus Wastes <br /> R Solid N.O.S. ORM-E NA9189 001 T <br /> Pt <br /> C. <br /> r �y. <br /> UV <br /> Alf <br /> .- P&68 ng s and Additwivalln cffT etlon <br /> 1' <br /> L• <br /> ENVI;, HEALTH <br /> are that the contents of this consignment are fully and accurate y de rt <br /> above bry proper shipping name and are classified.packed,marked,and labeled•and are in all respects in Proper condition for <br /> transport by highway according to appticabte international and national govemmantal regulations. <br /> Date <br /> Print carnef Sigr+atur / Month Day Year <br /> I r ' (- zf S13 <br /> T 17.Tra 1 A.ciutowiedoenwnt of Receipt of Materisis Date <br /> R <br /> A Pri Name Signator Month Dry Year <br /> I O1 �1 <br /> 0 18.Transpoi ter 2 AC knaw4edg ment Receipt of Material• - Date <br /> R <br /> Prirtted/'PyPad Hama Signature Month Day Year <br /> R <br /> 19.Discrepancy Indication.Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I 20.Fsciilty Owner or OPerstor: Certification of receipt of hazardous materials covered apt as noted in <br /> T Ium 19. P by this manifest except <br /> Y <br /> Date <br /> not ams lynature Month aY ear <br /> c <br /> Bluo- GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> OHS 4022 A(7/e4) <br /> (�PN•7170-22) To: P.O. Box 400, Sacramento, CA 95802 <br /> 64 sea•4 I <br />