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ate of Caulurnia—IIeaRM1 and Wellare Ag TOXIC• Department of Health Services <br /> Toxic Substances Control Division <br /> s Sacramento,Callfornla <br /> Please print or type. (form dB510n0d t0r Use on elite(12 pitch)type.,liar.) - <br /> UNIFORM HAZARDOUS enerators —Manifest est age Information In the shaded areas <br /> a _ - Dycument No i5 not required by Federal <br /> WASTE MANIFEST < G,1 O (f of aw <br /> A. tate Manifest Document Number <br /> er)eretor s Name and ailing Address .r r- ( r- I� O <br /> -Tr, B. tete Generators I <br /> 4. Generator's Phone <br /> -67 <br /> ransporser I Com—p—a-n-y—Wa—me US EPA ID Number C.State ransporter sQ <br /> ranapOrtef a hone7�7 '7`C l <br /> .. 1 ; ,.°(. <br /> . Transporter y ompany ame US EPA ID Number tate rancporter's D <br /> . ransporter's hone <br /> Designated Facili Name and its Address !to.— U EPA ID Number tete acility's D <br /> ( C aGl Ily a hone <br /> 2?J <br /> - 12.Containers <br /> AI <br /> 11.US DOT Description(Including Proper Shipping Name. Hazard Class, and ID Number Total Unit Waste No. <br /> No. T e 'Quantity_ <br /> Nr <br /> R <br /> A b. <br /> T <br /> � I <br /> IR <br /> C. <br /> d. <br /> /Pskar"PI)s IN: Mail IUsOsd =Handling Codes for Wastes t ve <br /> J. <br /> poria a inp nstruuYlona en i[ionsFinformartion <br /> 16.GEN ERATOR'S CERTIFICATION:I <br /> / T <br /> herebydeclare that the contents of this consignment are fulty and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and mein all respects in proper condition for <br /> transport by highway according to applicable international and national governmental regulations. pmonth <br /> ate <br /> Printed/Typed Name Signature ``^^ Day YearV v oi <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R M nt De Y or <br /> A inted/Typed am a ignatu s, O,yf_ <br /> Mn >o f <br /> - -- _ orate_..- <br /> o. t B.Transporter-2 Acknowledgement or Receipt-of Materists' - <br /> R Month Day Year <br /> TPrinted/Typed Name Signature <br /> E <br /> R <br /> 18.Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> I <br /> L <br /> I 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered <br /> r manifest exc s noted in <br /> T Item 19. Date <br /> Signature Mon <br /> ey Yser <br /> t not a/te (0 <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> OHS 8022 A(7/84) TO: P.O. Box 3000, Sacramento, CA 95812 w oral <br /> (EPA 8700-22) <br />