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MdO <br /> state o+C.ttornia—Heaith and Welfare Agency • Departments o6tr l Division os <br /> Toxic substances Control Dlvlilon <br /> 1 ]� Sacramento,California <br /> Please print or type. (Form designed for use on elhe(12-pitch)typewriter.) -TO V r <br /> 5-7 sn2 <br /> U (FORM HAZARDOUS eneretor s e. Manifest age Information int the shaded areas <br /> Document No. s not required by Federal <br /> A WASTE MANIFEST ' <1 e. 00 Z of iawl <br /> Generators Name and Met ress tete if t ument Number <br /> . tate eneretor a <br /> 4. Generator's Phone ( � 2 7 <br /> r <br /> ranapaser ompany me US EPA ID Number QStarte Transporter's 10 <br /> LG(i�FC !G " n (f /�•C7 3 3 ransportara <br /> 7. raniter Company Nam U EP ID umber tate. rensporter' <br /> as gnat sciliry Name an its rasa U A ID Number Sete aclli - - <br /> L /��oC,C`crtst luASi ��G- Q <br /> If 13Ox 3 sa ttr. tans <br /> ,esF�� �S� C,a t,. � . �.�� Fstis 3a � S <br /> 12.Containers 13. 14. 1.. <br /> 11.US DOT Description(including Proper Shipping Name, Hazard Class, and ID Number) Total Unit Waste No. <br /> No. Type Quantity <br /> a <br /> E a. �6{�� (Uf}s l s S;C / >S �-0 S a3ta-� <br /> N <br /> E �o/ � ,� . <br /> R <br /> ;s A b. <br /> T <br /> O <br /> R <br /> C. <br /> d. <br /> Listed-Above KH"Iup Codas b0r Wastes Utted <br /> 15.Special Handling Instructions and Additioral n ormataro <br /> AccF_? <br /> a <br /> 6_0 <br /> 16.GENERATOR'S CERTIFICATION:I herebydaclare that the contents of this consignment are fully and accura ely cribed <br /> above by proper shipping name and are classified,packed,marked,and labeled,and are in all respects in proper condition for <br /> trap highway,acaordin to a liceble interneUo 1 and n oo al go v ental r ulations. <br /> Wort by 9 Y y,�.�'7�T as G—X�- •f�llz.[J39 Date <br /> Printed/T Nem fig /�� Signature � MonA Day Year <br /> UY <br /> T 17.Transporter 1 Acknowledgement of K809ipt of Materials 1Date <br /> A Printstt/T Name Signature Month Day Year <br /> N e e <br /> rehttpoffst'2 4,,* wlstlpe M. or..Receipt .of;;; <br /> ls .-;... ..._...:. . ..--.-... -- -.. ..- -.Date. <br /> T Printed/Typed Name Signature month OeY Year <br /> a <br /> e <br /> 19.Discrepancy Indication.Space <br /> F <br /> A <br /> C <br /> 1 <br /> t <br /> 120.Facility Owner or Operator: Certification of receipt of hazardous materiels covered by this manifest except as noted in <br /> Y <br /> T Item 1g. Dets <br /> not me ignetur Month 1y Year <br /> s oZ <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> Pro41 <br /> (EPA 61700-a2) TO: P.O.Box 3000, Sacramento, CA 95812 .� <br />