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State of Callt orma—HeaiUr antl Wolfs re Agency Department of H..,+t erVRes <br /> TOXIC Substances Control Division <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) ' <br /> UNIFORM HAZARDOUS enarators o. Manifest ape normation in the shaded areas <br /> Document N of is not required by Federal <br /> WASTE MANIFEST /� ��9� C law. <br /> 3. Generator's Name and ailing Address �7 Ag <br /> � men) Number <br /> 4-/1 a7-1 r JL <br /> �F SIL� A v'� /L1ol�F S/ a �A I?) S late Generator's 10 <br /> 4. Generator's Phone ( C I <br /> 5. ranspotaer ompany Name .n /US <br /> EPA ID Number C,Stato Trimsporter f - <br /> strisporter's Phone <br /> rensportermpany ame U EPA ID Number 00 Ianiporlers <br /> o <br /> rallsptlrtN• <br /> nDesignated Facility ame and Site ddress 1 US EPA 10 Number te tpacil s_10 <br /> f / nL�G/wt W.45 'Y AuL74 70 aclltys <br /> 5 D 55 <br /> - <br /> 12.Containers 13. 14. 1. <br /> 11.US DOT Description(Including Proper Shipping Name, Harard Class, and ID Number Total Unit Waste No. <br /> No. T e Quantity <br /> c <br /> E e. <br /> Fit <br /> A b <br /> 4 T <br /> 0 <br /> R <br /> C. <br /> d <br /> y f t &H midt rp Codes for Wastes VT <br /> 15. <br /> Special Handling Instructions and Additionalnormal <br /> 16.GENERATOR'S CIENTIFIC;ATION:I <br /> hereby declare that the contents of this coming:nmeMare ullyandaccuretely,ascribed <br /> above by proper shipping name and are classified,packed,marked,and labeled,and mein all respects in proper condition for <br /> transport by highway according to applicable international and national governmental regulations. <br /> Date <br /> rinted/Typed Neme Signetwe Month Ye <br /> 68 ar <br /> Grp Z <br /> Date <br /> T 17.Tran rte 1 Acknowledgement of Receipt of Materiels <br /> A fe Mont Day Y e <br /> A Print Nama /., <br /> D. <br /> N alit �M Z 1�i/ e. <br /> ..__-`s.18.Tisnaportor 2 Acknowledgement or Receipt of Me Is'. - _ - - Dere <br /> A - Monfh Day Yes <br /> T Printed/Typed Name Signature <br /> E <br /> a <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> L <br /> 1 20.Facility Owner or Operator: Certification of receipt of hsmrdous materials covered by this manifitat except as noted in <br /> T hem 19. Date <br /> v <br /> i L Month ay s'er <br /> rt Name gnsur f go r o <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> PNS 8022 A(7/84) TO: P.O.Box 3000, Sacramento,CA 95812 04 awl <br />