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• • <br /> State of Calif oro la—Healih and Welfare Agency Department of Health Services <br /> Toxic Substances Control Division <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-p0ch)typewriter 1 <br /> UNIFORM HAZARD enerators o. anlest age normationinthe shade areas <br /> Document No 01 is not required by Federal <br /> WASTE MANIFEST 7 2Y Doc o' <br /> Generator's Name and Mailing ,Address a n u Number <br /> tatheralms <br /> 45.. Generator's Phone <br /> ranspooler company Name U AID umber _ Wagoner s IO. S <br /> FeMpOnerf <br /> . ransporter om & us EPA ID Number tate ransporters <br /> IDF. <br /> f <br /> Designated9. Facility aff/tgn�e�� and ite ess U A ID Number -. s <br /> l�G ooX . ��� • aYs ons <br /> 12.Containers <br /> 11.US DOT Description(hlNuding Proper Shipping Name, Hazard Class, and 1D Number) Total Unit <br /> No. T Qua nti <br /> R <br /> A b. <br /> I <br /> 0 <br /> R <br /> C. <br /> d. <br /> forriNwitersUatedlAbove t+. <br /> pecial Handling Instructions and Additions] Information <br /> A// �CG��i�G� �- LT/� <br /> �,(av2�-S — ai 5 – &62G -1IS.GENERATOR'S CERTIFICIMUW'. s <br /> erebydeclere that he contents this conaignmerx are ullyand accuretelydescribed <br /> above by proper shipping name and are classified,packed,marked,and labeled,and are in all respects in proper condition for <br /> t <br /> transport by highway ager ng to applicable international anO nationalpov grnm�eMal regulations. Data <br /> T �J <br /> Month DeY Year <br /> ±Printed/TyWName Signatureif ff Frdryl�61i m¢ o�u. DateF 17Aclowledgemem of eceipt of MaterialsR Si nMonts DeY Y er <br /> h Na s g <br /> fcoo <br /> r 0 <br /> a., 18,,Transporter 2 .Acknowledgement or Receipt .04 Materials .. ..... Data - <br /> R Printed/TypW Nama Signature Monrh Dey Yasr <br /> E <br /> R <br /> 19.Discrepancy Indication.Space <br /> F <br /> c <br /> C <br /> 1 <br /> L <br /> 120.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manilQst except as noted to <br /> T hem 19. Date <br /> y <br /> Int ame <br /> poet a Month way Y ear <br /> o' 1 <br /> e- F <br /> White: TSDF SENDS THIS COPY TO DOHS WIT 30 DAYS <br /> DFS$022 A(7/84) TO- P.O.Box 300,Sacramento,CA 95812 M NMI <br /> (EPA$700.22) <br />