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State a1 Cal Itorn la—Health and Welfare Agency 4 Department of Health Serylces <br /> V Toxic Substances Control Division <br /> Sacramento,California <br /> Please pr,nt or type (Form designed for use on elite(12-pitch)rypewrner) <br /> UNIFORM HAZARDOUS Generator s o. Manifest age Information in the shaded areas <br /> WASTE MANIFEST -CAD 9 81158 9 8 3 u ° t L.not squired by Federal <br /> . <br /> enerstor s Name and Mailingrasa tae anifest Document Number <br /> California ept. of Transportation 4 O <br /> 1975 E. Charter Way <br /> 0366 <br /> Stockton, CA 95201 tateGenerator's ID <br /> 4. Generator's Phone f 209 935-2076 <br /> 5. ranspomar I -ComDeny NamG 9. LIS EPA 10 Numfr-r .Mate ransporter <br /> Chemical Waste Mara. e:nen1AD 0 8§718- <br /> ranaporters ones . , <br /> ranaporter pang Name U PA ID Number tete Transporter's 10 <br /> 7. . . . . . . . . . . Transporter's Phone <br /> 9. ignat acv ltyNam* a iteresa 10. U tats act ID Number taact a <br /> Chemical Waste Management, Inc . <br /> 35251 Old Skyline Road <br /> Kettleman City, CA 93239 ' aartys - <br /> CAT©00645117. C;;> C?12.Containers 1 14. <br /> 11. US DOT Description(Including Proper Shipping Name, Hazard Class, and ID Number) Total Unit 1• <br /> p No. T uanti Waste No, <br /> s a. <br /> M <br /> e Hazardous Waste Solid N.O. S. ORM-E NA 9189 . DT Y _':,6]1 ; .?' <br /> R <br /> A b. <br /> T <br /> U <br /> R <br /> C. <br /> k; <br /> d. <br /> s <br /> 5'O s.11Qr4►5t '— aJ 7�/°!31' y a,t►L,6p•++s IL Handling for Wastes <br /> ��! �C Wi.,..;ate .` �.•. .,.._. y.._ .. .. t -a - ._ .. ' <br /> 45 <br /> Special Ing instructions. and AdditiOrialinformation , <br /> 16.GENERATOR'S CERTIFICAT16IN:I hereby declare that the contents cithis consignment are fully and accurately described <br /> •above by 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 applicable international and national governmental r ulations. <br /> Date <br /> ted/Typed <br /> Na !� Signartur Mo h Ray Year <br /> A,L �� r.�T!" �� <br /> T 17.Transporter 1 Acknowledgement of Receipt of MaterialsQate <br /> A Pri Name SI t r Month Day Year <br /> N t 10M <br /> 0 18.Transporter 2 Ack m <br /> edgeant or R pt of Materials' Date <br /> Printed/Typed Name Signature Month Day Year <br /> R . <br /> 19.Diserepericy indication Space <br /> f <br /> A <br /> C <br /> I <br /> L <br /> 1 20.Faclli Owner or Operator: Conifiaation of receipt of hazardous materiels covered by this manifest except as noted in <br /> T item1 S. 'If Al <br /> Data <br /> int me f rgnature Mh D <br /> ' <br /> oxk%* ,4e,vb., <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS t <br /> a A f�/x4) <br /> (EP TO: P.O, B3DO0, Sacramento, CA 95812 <br /> ft=_PA 9700-22) ox acramen <br /> .. ' i<a$slsFtt ':. <br />