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• . Department of Health Services <br /> State of Calltornta—Health amid Welfare Agency Toxic Substances Control D)vl Sion <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite 112-pitch)typewriter) <br /> UNIFORM HAZARDOUS eneretors ° Document o1B/ Iawnotalion in the requiredsbyded Federal <br /> WASTE MANIFEST 9 d o 89S'��� <br /> ePne�rai toar ls �am�Geyn/ Mailing t e(_ 4,nest acumen <br /> men[ umber <br /> 4 � 3 ' <br /> I6 <br /> .t _ <br /> tete Generator's ID <br /> 4. Generator's Phone ( p 1 <br /> renspower Company Name U EPA ID Number7. tete Transporters <br /> D.Transporter's Phone <br /> Transporter 2 Company ame US EPA ID Number E.51sts TrensportW's <br /> F.Tral wits Phone <br /> Resign7ed Facilityme and Site ddress U E A ID Number /Mats a <br /> PD 6�` 336 <br /> 4Phone, <br /> /J <br /> 33�5� .¢.D9 B.oE. 2T 276 a'ar� 3L5--STS-" <br /> 12.Contalners 13. 14. I <br /> 11.US DOT Description(including Proper Shipping Name,Hazard Class, and/D Number Total Unit Waste No. <br /> No. T Quantity <br /> 0 <br /> a <br /> T b <br /> O <br /> a <br /> C. <br /> d. <br /> ILHandling Codes for Wastes <br /> t � V f9"^ <br /> 1 � <br /> pacts a ing Instructions a rtiona n orrnetan <br /> -/ <br /> Acc,,, 4,joF- -W- C--18/ <br /> hereby 5;@i1l;ffiii the conto.Its o this toneignmeM are ullyand accurately de scribed <br /> above by proper shipping name and are classified,packed,marked,and labeled,and ars in all respects in proper condition for <br /> transport by highway according to pp1i ,W�nternationa and nationaI go ver ntal regulations. Date <br /> Printed/Typed Name Spnatur9J Q Monrh Dey Year <br /> �r�JQ.�✓ Y/� moi./ <br /> T 17.Transporter 1 AClcrwwladpement of Receipt of Materials <br /> Date <br /> Printed/Typed Nams Sign 1 month Da Y <br /> 1 SIJ .... . ? �. .. � <br /> a - V 1 _.. O.U . �.� _.,.. <br /> . . - o 18rdranaporver 7 -AclmRtded ti none or R"ipt of Materials .- - .Date- <br /> 0 <br /> ata.. <br /> T Printed/Typed Nome Ignaturs Month Day Year <br /> E <br /> e <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> L <br /> I 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this menitgst except as not In <br /> tT, hem 9. D.0 <br /> tprutur Monrh may ser <br /> mt ame , <br /> S <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> DHs a022 A(7/84) TO: P.O. Box 3000, Sacramento,CA 95812 w M41 <br /> (EPA 8700.22) <br />