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I Deaartmant of Hsalth Servio <br /> Toxic Substances Control Dlvlrlc <br /> + SaCramento, Gllforn <br /> Please print a tyve (Form des' nod for use on elite(12-pitch)typawritar) . . <br /> UNIFQRN! HAZARDOUS enerator sNo-- <br /> Manifest age !nformation in the shaded areas <br /> WASTE MANIFEST CAI]981.15$'�83 . DOe m "i is not required by federal <br /> enerstor ma n ilin ass law. <br /> ta' If'�rn a hep , of Transportation � n� ej ment umber <br /> 1976 E. Charter Way 64 <br /> Stockton, CA 95201 tate eneratorrZ <br /> 4. Generators Phone 2 0 9 935-2076 <br /> 5. rsnspower pang ame U umber <br /> tate ranaporter a <br /> Chemical Waste ManagementZ,,C X AD00.39867.16 . . . - <br /> nnaporter's - <br /> ranaporter ampany tme US EPA lG N4mber tate ra <br /> nsporier s <br /> ignat o f a e a Its rens U A Number - <br /> emaca' ' r7ase anagement, Inc. the s <br /> 35251 Old Skyline Road C <br /> Kettleman City, CA 93239 astl <br /> :CATO 0,0 6 4 61.17. <br /> 11.US DOT Description Plnclucling Proper Shipping Name, Hazard Class, and!D Number 12.Containers Total U14. <br /> nit ..''i`. <br /> t1 <br /> t a No. T Quarto Waste No. <br /> Hazardous Waste Solid N.O. S. ORM-E NA 9189 DT <br /> r , r <br /> R Y <br /> b. La <br /> T <br /> G <br /> d. <br /> peow4itim" fair Materials Above <br /> A - <br /> � r: �►� ,$�yJt�, '"V �.�/"�. :Y'/1'"'-'�4�'��'S` +,I, �� L 1AfastesLhftod <br /> Above <br /> cc - <br /> . .� Y fr+ .�.t,r,'I'4�'7�,�.4 i � 1 - .• V�F� T y+ .i+_� 'w +�w -1 <br /> 5. <br /> -4 - <br /> Special inn instrumions a Itlona ormation <br /> i <br /> 16.GENERATOR'$ <br /> i <br /> •I herebydeciare that the contents o this consignmemara fully and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and are in oil respect*in proper condition for <br /> transport by highway according 10 applicable international and national govern ntaI ulations- <br /> qtr rrAA CCTT Date <br /> rr a ' <br /> Signatur Monrh Day Y ar <br /> T 17.Transporter 1 AcknO-fedgement of Receipt of Materials <br /> Date <br /> A Print YPb Sarno Signature Month Day Year <br /> / o s <br /> 0 18.Transporter 2 Acknowledgement or fteceipt of Materials _ Date <br /> a <br /> EPrinted/TypedName Signature Month pay Year <br /> 19.Discrepancy Indication.Space <br /> f <br /> A <br /> C <br /> 1 <br /> IL <br /> 1 20.Facility owner or Operator: Certification of receipt of hazardous materials cowered by this manifgxt except as noted in <br /> y Item 19. <br /> int Date Name nature <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (EPA 6700-22) <br /> DHSS 8022 (7/a4y TO: P.O. Box 3000, Sacramento, CA 95812 <br /> 04 ON4 t <br />