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• • Department of Health Services <br /> ytate of Callfornla—Health ano welfare Agency Toxlc Substances Control DIVISIon <br /> Sacramento,Callfornla <br /> Please print or type. (Form designed for use on elite J1 pitch)typewriter.) <br /> UNIFORMHAZARDOU$ enerators o. anlest age ad areas <br /> /, y �C Doc ment No. of i5 not regwred by Federal <br /> WASTE MANIFEST law' <br /> enerator s am <br /> and ailing Ad"S. t" lest Documem Number <br /> � 87 <br /> tete erfaratmis <br /> 4. Generator's Phone ( 1 �� <br /> ranspower omp, ame U EPA ID Number tete ranspomit a <br /> L, n Ci .4 .( Z i i-49,9, ranspon t S 3 <br /> Transporter TO <br /> 7. Company Name U EPA ID Nuronsportatt <br /> ra a t <br /> 9. <br /> gl4esignat acility Name and ite d/gess U 10 <br /> EPA ID Number tete- ecil C <br /> �O c 33 fifty. / <br /> r X <br /> 12.Containers 13. 14. <br /> 11.US DOT Description(Including proper Shipping Name, Hazard Class, and ID Number) Total Unit Waste No. <br /> -- <br /> No. T Ouantity I'll <br /> E <br /> of <br /> A <br /> k b. <br /> T <br /> 0 <br /> R <br /> C. <br /> d. <br /> n <br /> .. . KHatWlinp Codtt for wettes ..... ': <br /> - <br /> 4 0. I .gtyo g.f f7 ti i > <br /> 15.Special Handling Instructiois a inone n ormatan/ <br /> hereby declare that the contents thiswnsignmelK are ullyand accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and are in all respects in proper condition for <br /> transport by highwey according to applicable international and national governmental regulations. Date <br /> Is 'nted/Typed Name Signature Month Vey Year <br /> 1 ff. <br /> Date <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> Pr(nted/T Name Signatur Mo Day Year <br /> N <br /> a // <br /> `... _�_. 0 18.-Tronsponer 2 Acknowledgement or 1111903011 of Matariala' _.._ Date - <br /> t Printad/Typed Name Ig If to Monrh Day Ye r <br /> E <br /> R <br /> 18.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> t <br /> 1 20.Facility Ower or Operator: Certification of receipt of hazardous materials covered by this manifgst except as not In <br /> y hem 18. Date <br /> ftnilli LOS Month way <br /> ear <br /> W Ol <br /> �GV4 ,-A g� <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> EP 6A 67700 0-22)-2(7/84)) TO: P.O.Box 3000,Sacramento,CA 95812 ' <br /> (.P' 1 ( .::-,. <br />