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State dT Calliornla-Hulth and Welfare Agency Department of Health Servlc <br /> Toxic Suortances Control Dlvislc <br /> Sacramento, Cailtorn <br /> Pleasopr nt or type (Form designed for use on elite;l2-pitch)"writer.) <br /> F4. Gonoranor's <br /> FORM HAZARDOUS Generator's o. an. est age n ormation in the shaded areas <br /> ASTE MANIFEST CAD981155983 tt is not required by Federal <br /> law. <br /> ator s Name and aiiin cess tLI nife mens umber <br /> California Dept. of Transportation 4 O <br /> 6 E. Charter Way ut. enerators <br /> kcPno,neCA2092g1935-2fl76 <br /> rons"r 1 Company Name US EPAI umber CState Transporter's IDf <br /> Waste Mana ement CAD003986718" . nfanspotzer'se ° 4 <br /> 7. ransporter 2 Company Name . US EPA ID Number EStato ranspo3rzw s <br /> . . . . . . . . . rensporter s Phone <br /> 9. signated Facility Name and Site Abdiess 10. US EPA ID Number QStats acuity s 10 <br /> Chemical Waste Management, Inc . <br /> 35251 Old Skyline Road Rcj_ <br /> Kettleman City, CA 93239 Pboi- <br /> CAT0006.46117. a5t s <br /> a 6- 7 <br /> 4. <br /> 11.US DOT Description(including Proper Shipping 1 .Containers 1 ini <br /> p 17 per pilin Name, Hazard Class, and ID Number Total Unit '.' � I• ' <br /> c No. Type Quantity :XrVMiasts Na. i <br /> E a• a <br /> E Hazardous Waste Solid N.O. S. ORM--E NA 9189 DT Y <br /> Tib. — - <br /> C. <br /> 2 <br /> d. <br /> »I VYihecyf-TFSpec . ' L rj F� •fr �i ,r�.rr .� i i .�.. xw t..ti. _."�Y 4i �ti,�*•;�1t•h- <br /> ia. Kandling inxtructions and AdditionalInformation <br /> 16.GEN ERATOR'S CERTIFICATION;I hereby aWciare that the contents ol this consignment ore fullyand accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and are in oil respects in proper condition for <br /> transport by highway according to applicable international and national governmental regulations. <br /> p Date <br /> Pri ( me 1 e ,4 � Stgnatu Dia Ya <br /> r i- + ' I <br /> R 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> A Pr' ted/T. No Signet Atonrrfh a yeq <br /> R <br /> 0 1$.Transporter X Acknowledgement or Receipt of. Materials' Date <br /> le <br /> T Printed/Typed Name Signature Month Day Yea. <br /> E <br /> , <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> L <br /> t20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manNga <br /> t except as noted in <br /> T hem 9. <br /> r ' ' Dat• <br /> Printed/Typed ameigneture Monrh a <br /> OHS o22 A I7/sL? <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS t <br /> s • <br /> (EPA 0700•zu) TO: P.O. Box 3000, Sacramento, CA 95812 <br /> _ ....r•-eta:,.r.,..._. _'' . . . i '��y <br />