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• • Department of Heallh Services <br /> Slate of Caldor a—Heallh and Welfare Agency Toxic Subslances Control Division <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12 pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST CLQ /�?W �i oocu of / is not required by Federal <br /> law. <br /> 3. Generator's \ame end Mailing Ad / A.State Manifest Document Number <br /> 84692887 <br /> 9Dgt�v W� W, F-$,-Q/ �J 3=� B.State Generator's ID <br /> 4. Generator's Phone( ) <br /> 5. Transporter 1 Com ame 6. US EPA ID Number C.State TrenspQrteetir�.,{D� <br /> ' . D.Transporter's. lhon;i b <br /> 7. Tran rt2 ompany Name 8. '- US EPA ID Number E.State TrsnsparteCa. D«. V <br /> .( � . F.Transporter's Pilon' p$r- <br /> 9 Designated Facility Name and Site ddress 10. S EPA ID Number O.S ate Facllirysi0:=` ' <br /> %.eo �1 lU/r4s�i �•UG <br /> H.Facllity'6 one - <br /> a7 �S a�'S3Ss <br /> 12.Containers 13. 14. <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class,and ID Number) Total Unit Waste No. <br /> No. Type Quantity tivol <br /> G <br /> E ge4el)2&-S OAS,- Xc <br /> 74-/D-S I.05 a)eA 0 � Q r <br /> A b <br /> T <br /> o <br /> R <br /> C. <br /> a <br /> d. <br /> �. <br /> F ddl vssetiptio t IAat¢AslsedNAppve'U Handling Codes for Al atl ft:tedX6oYe <br /> 00 <br /> .n 00 <br /> 1ICT <br /> �' Tei.✓' .:A# t- Rk`�a�.^5+,"":.. _ vG7; "a"'.'?.� n u .:.y= a <br /> 15. Special Handling Instructions and•Additional Information <br /> 690 - �s <br /> 16.GENERATOR'S CERTIFICATION:I hereby declare that theconlents of this consignment are fully and accurately described <br /> above by proper shipping name and are classified,packed marked,and labeled,and are[nail respects in proper condition <br /> for transport by highway according to p licable International and nations governmen I regulations. Date <br /> 4C.G r iF.Ui <br /> PrintedlTyped Name Sigga�uro ,/� Month Dey Veer <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> ,Ai Printed/Typed Wme Signature Month Day Year <br /> - o -18. Tran porter 2 Acknowledgement of ReceiptofMiMittele - "' Date <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> 20.Facitlty Owner or Operator:Certification of receipt of hazardous materials covered by this m t except as noted in <br /> I Item y9. Date <br /> T <br /> v PrintedlTyped ame/ / Signature Month Day Year <br /> //✓►� /L�f✓/�'s�✓ G O <br /> -I rzi <br /> DHS 8022 A(11/64) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS 6489641 <br /> (EPA e7Q0-22) To: P.O. Box 3000, Sacramento CA, 95812 <br />