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Denvtrnem of Health Service, <br /> State of California—Health and Welfare Agency ioxic SAstances Control Division <br /> Sacramento.California <br /> Please pint 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 uthe shaded areas <br /> WASTE MANIFEST / <br /> Document-Umof s not required by Federal <br /> 19 37 aw. <br /> 3. Generator's Name a d Mailing Address A.State lidg; t o urtlent Number <br /> 84 <br /> JES/O C 7'S"3B.State_Geennerator's ID <br /> 4. eneratois Phone <br /> 5. Transporter 1 ComPAP* Name 6. US EPA ID Number C.State Transp rtePal =s`, <br /> D.Transporter'sPhone <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E.State TranlpOrter's ID <br /> . . . . F.TrensportePs Phone. <br /> 9. Designated Facility N me and Site A9dress 10. US EPA ID Number G.StateFacility's ID <br /> , <br /> H.Facllity's Phone <br /> 12. ontainers 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 /> R Do/ Dr <br /> A b. <br /> T <br /> 0 <br /> R <br /> C. <br /> d <br /> _ } pescrlptilxls E �y ytbc� tC.Handling Codes for Wastea Listed Above <br /> Al <br /> 15. Special Handling Instructions and Additional Information4 <br /> 00 <br /> gLo v FS K-a�s J as <br /> 16.GENERATOR'S CERTIFICATION:I hereby declare that thecontents 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 highwayac orQing to applicable Int rnational d nat��,peTmental regulations. Date <br /> �.0 T U L <br /> PrintedlTyped Name Signet (+ Month Day Year <br /> T 17.Transporter 1 Acknowledgement" of Receipt of Materials Date <br /> RMonth Day Year <br /> A Printed/Typed Name ign lure <br /> 0 18.Transporter 2 Acknowledgement of Receipt of MateI - Data <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. Itemllty�Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted In <br /> 1 Date <br /> T <br /> r T Printed/Typed Name Signa �_� Month Day Yea <br /> O <br /> Whiter-TSDF SENDS THIS-COPY TO-DOHS WITHIN-30 DAYS -- <br /> DHS 8022 A(11/84) e�see11 <br /> (EPA 8700-22) To: P.O. Box 3000, Sacramento CA 95812 <br />