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State of Califamia—Health and Warta,Agency Department of Health Services <br /> xm APPMe ed OMB Na 2050—OD39(Expires 9-30-91) SM IIISLIUG}LOOf 00 Lg(FCr. :page Q. Toxic Substances Capitrol Program <br /> Please pont a type, Form designed 0.y use an elite(12-pi rypewrifer) Sacramento,Califomia <br /> UNIFORM HAZARDOUS 1.Generators LIS EPA ID No. Manifest DocurriNo. 2.Pagel Mo ma onnthe sradetlareo <br /> WASTE MANIFEST 'l 1 `I I I -I I I I I of - erot required by Eedeallaw. <br /> J.Generators Name and Mailkpg Address - ` A.Stale momit t pocurimm Number*'f i�s <br /> 33314 <br /> $, ate s `vt Q <br /> 4 Gerserato/s Ptane <br /> 5.Tromporter 1 Compory Name t^ 8.LIS EPA ID Number 1 _ -^ C.Store,Transporters ID <br /> L '. 1. - 'I'1 1 II l I I •I I r 0.TmnWorteq PfgrM <br /> 7.Traroporter 2 Company Nona 8.US EPA ID Number1 <br /> F Stare Trarepo(tats 1D <br /> I I I I I I I £Tran &Phone <br /> 9 Desaxamd Facet Pkrm amp$t%Md" , +L r r.r 10.(A EPA ID Number G-:SfatsFabNysJD, <br /> +It t' 14.1 .1 41 «E a t *f 7 <br /> T-�i FPg1Ah/f Pharre: <br /> 3Xf 1z.cpnrainea la Told ^la UM <br /> 11.Ib DOT Dsacrtptbn(hckabg Proper SMppkpg None.Hazard Clas,and 1D Number) No. i 9uo+1 WI/Vol 1 Via"Number <br /> J <br /> a state <br /> L, <br /> L[ l ,I 1 1 ,I I <br /> �5z N <br /> (V)ab. <br /> E slate,F <br /> 00u- R <br /> MU A <br /> T <br /> C. shah <br /> O <br /> �3 K EPA/Cither <br /> I I I I I I I <br /> 0 d s <br /> m <br /> 0 <br /> N <br /> y <br /> J,Additond Descrlpfion fOr efod Ahave Klbndlmgfotles 7osWmtes l.¢ted Above <br /> 44, <br /> ATI <br /> c <br /> w <br /> Z <br /> w <br /> U 15.Specid FipntlYrp Irsmctlorn and ACkieiorpd Infonnaflon <br /> a <br /> u <br /> cf <br /> c <br /> j Z I& GENERATORS CEirnFICATION: I hereby deckire that the contents of the corepnmerif are fu and accurate descnbed above <br /> packed,narked.oa bbebd.and are in all res N io proper shiPpkp none irr oe classified. <br /> . <br /> O pacts kp paper corpditbn for horauport by hlghwoy according to appacabk irrtertpatkpnd and nationd gowmmersl regubtkpns <br /> CIT I an a Inge aufsntitY generator.I certify that I have a program n place to reduce the volume mtl toptldly of waste generated to the degree I have detembetl to be <br /> z e 011011 0011'piaatka IQ and mot I have sebcmd me placticabe Method of treahnerrt,storage,or deposd cu"mly avdbble to me whbh nxri M,,me the pe lent and future <br /> w Rveof to hunm heUh era the ervlorvnera:OR,d I on a may quantity ger»rota,I have mode a good faith effort to minimae mN%rale generation aria select the best washe <br /> = maagetrent method that a avabble to me are that I can afford <br /> J <br /> Q PrintetllTypetl Name signature W`im Day year <br /> i U <br /> H T 17,Tra m"er 1 AcknowNtfgement of Receipt of Mdenae I <br /> pR 7;; d/TYped Name signature Month <br /> > A Cb year <br /> U N <br /> Z S <br /> JuP <br /> c 0 18.Transporter 2 Ackriowledgemerit of Raceipt of Materiae - <br /> uu R PMted/Typed Nome slgnahee Month Day ✓ear <br /> Ui T <br /> O <br /> E <br /> w R <br /> Q F 19.pacrepatay halcation SiPoce I <br /> U A <br /> z C <br /> I 20.FadYly Owner or Operator Certification of receipt of hasamou materials crovered by me manifest except as noted in item 19. <br /> T Pmted/TYped Na MeSignature Month Day Year <br /> Y <br /> I 1 I 1 I <br /> DO NOT WRITE BELOW THIS LINE. <br /> DH58022A(12/90) Yellow: GENERATOR RETAINS <br /> EPA 87OD-22 <br />