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State of Califomie--+teaith and Welfare Agency Department of Health Services <br /> Form Approved OMB No.2050--0038(Expuee(F3691� Toxic Substances Control Division <br /> Please print or type. (Form dsagrrotl la We on este(1_ fch typewrtter). . J Sacramento,California <br /> UNIFORM HAZARDOUS I. Generator's US EPA ID No. Manifest 2. Paget Information 4 the shaded areae <br /> WASTE MANIFEST L Q L/Q d Q o 41m I "i a Is not required by Federal low. <br /> 3. Generator's Name and Mailing Address A- State Manlfaat Documam Number <br /> NV it JAI Z,A1C, <br /> --),1,1 3 n 0/ N W12 O S State Genantoea ID <br /> 4. Generator's Phone( Q�) ;3�_ 5�9 LS �. 9(��i 0lV C9 9.530 <br /> u6. Transporter 1 Company Name 8. d (� US EPA IID NumberC.C. State Tnnsporter's 10 O <br /> c^u P P Clrl J y I 6 3 6 6 TransPonar's Phwlar - /9`I -7 <br /> CP 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's 10 <br /> g F- Tronsporter's Phone <br /> 9. Designated Facility Name and She Address 10. US EPA ID Number (L State Facility's ID <br /> 11 3 H. Fecigy' Phoria <br /> Z �n .✓ JJ L L 7 A/ ,7 <br /> CIA, -1)11 01417 'I,,21:716 0 - 3141 <br /> O 12. Gontainare 13. Total /4. I. <br /> W 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> a <br /> No. Type Wt/Vol <br /> V a' �- .�L � .:ir r7 yTC ✓] !J; r o/v l� State <br /> Z G <br /> 1=- E r /ice. J '- :��C�i! -t� ,i`,nJI �1 iN i <br /> 3 N f ✓'9 -�sa O + L O f 0 ! G O G ! J EPA/�x Y <br /> oR b' ' tete <br /> m A <br /> O ,....,. ,�. .'kTrtT (; V �.}: EPA/OH1or <br /> N <br /> � R a Stele <br /> $ hEUB(EIry WINE<. <br /> EPA/Other <br /> d' State <br /> W <br /> U <br /> EPA/Other <br /> Z J. Additional Descriptions for MaterialsListed Above K Handling Codes for Wastes Listed Above <br /> 03 <br /> ¢ a d. <br /> Z <br /> Ny),QoCAA45o J 5 pP ►,t - <br /> O <br /> Q 15. Special Handling Instructions and Additional Information <br /> Z <br /> =r+F <br /> J <br /> J <br /> < 1e. <br /> U <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and are classified,packed,marked,and labeled.and are in all respects in proper condition for transport by highway according to applicable international and <br /> d national government regulations. <br /> y <br /> ¢ If I am a large quantity generator.I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> U to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> } present and future threat to human health and the environment;OR,it I am a smell quantity generator.I have made a good faith effort to minimize my waste <br /> U generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> w Printed/Typed Name Signature <br /> g / Month) Day Year <br /> W T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> QN Pentad/Typed Name Signature Month Day Year <br /> t <br /> W n / <br /> 101 <br /> W O 18. Tranaportes Acknowledgement of Receipt of Materials <br /> Q T Printed/Typed Name Signature Month Day Year <br /> V E <br /> 2 <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T <br /> Y Printed/Typed Name yJJ Signature Month Day Year <br /> DHS ( <br /> A 8722 i/ee) Do Not Write <br /> EPA 8 022 A(1 ,$alow This Line Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> - 6' <br /> (Rev.9-88)Previous editions are obsolete. <br />