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• • Department of Health Services <br /> State of California—Health and`Aelfare Agency Toxic Substances 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 IDN Manifest 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST e Docume is not required by Federal <br /> V oflaw. <br /> 3 Generatorb' Narl and Mailing Addr be <br /> S _ A.State Manifest Document Numr <br /> crq�,) 84692996 <br /> / , � // B.Stete Generator's ID <br /> - <br /> 4. -Ove Kro���ogs3s/ <br /> 4. Generator hone( <br /> 5. Transporter 1 Comp pK ame 6. US EPA ID Number C.State TranaporteesjD-,, FJ <br /> DTransporter's,Pho46r <br /> 7. Transporter 2 Company Name s. US EPA ID Number E.State Transporters JD <br /> . . . F.TrahSporter's Phone <br /> 9. asignated Facility Name and Site Addr ss 10. US EPA tD Number G.StBte'Facility's ID <br /> /II s <br /> o'Sld .5 H.Psof� �a ne 5a J J <br /> 12.Containers 13. 14, <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class,and ID Number) Total Unit Waste No. <br /> �j/1�������//�.�' /�[A ,`�, ),�1� No. Type Quantity tivol <br /> E ,1f NKA W4-Sl S4JZ5 I✓• 05 <br /> S R fill <br /> A b T <br /> T <br /> 0 <br /> R <br /> C. <br /> d. <br /> CD <br /> CT) J.� tldltiotul Descrtptions ;:,�ilaterl 1p _ �lhove w; ,t*- j; �.' "andfing Codes for Wastes Usted�4poYe. <br /> CT) 71 <br /> 'V 15. Special Handling Instructions and Additionnaall Information <br /> 00 /7rG /+rdRJG�f� - V / V <br /> G V ii:-S - �o66el, S — 4V <br /> 16.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and are in all respects in proper condition <br /> for transport by highway actor n to applicable Internal i nal a national gov nm rdal regulations. <br /> 6,6 af' L ;�J Date <br /> PrintedlTyped Name Slgnaol Month Day Year <br /> T 17.Transporter 1 Acknowledgement d1 Receipt of Materials Date <br /> R rinted/Typed Name SI re Month Day Year <br /> P e LE'(J� S _ <br /> - '- - o .-T artbparter-2'dcknowledpement of Recelpi of Materials 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.Faclllty Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted In <br /> I Item 9. Date <br /> T <br /> v <br /> Printed/Typed Name Signa Month Day Year <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> - _ pHs 8022A(11/84) To: P.O. Box 3000, Sacramento CA 95812 84e9e41 <br /> (EPA 870022) <br />