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• , <br /> Department of Health Services <br /> Slate of Caldornia—Health and Welfare Agency Toxic Substances Control Division <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. an est 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST �}. .q. i. S Docum t of iawnot required by Federal <br /> 3. Generator's Name and Maung Address A.state Manifest Document Number <br /> B State generators ID <br /> 4. Generator's Phone( ) <br /> 5. Transporter 1 C�any ame 6. US EPA ID Number C.Bt4te.'7Y4tfepC(tel' �� <br /> GU ,4 if e.4-i) ,. .g_3 " DTran*nt: n$ <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E.Stat e-TYgnapbrle'r`.H', D <br /> Prranspo: er, , -, .. <br /> 9 Designated Facillty Name and Site Address 10. US EPA ID Number ;S tote:£aolllt�4s�Di�... <br /> 1'J-i i2oc E-u M <br /> PD �o�C 3 3 <br /> ilk LI C.CI/' �3�� CyA 5�7. �: e3 �-�u <br /> 12.Containers 13. <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total unit `Waete}l <br /> No. Type Quantity tlVo <br /> G c J <br /> N 7� .A'0Z)e5o S 1&'r, S/�C' JCL I 3c <br /> R <br /> E 1&'r, e?r Lr /� t K <br /> T b ' . <br /> R <br /> C. rxr <br /> d. <br /> t ., ..t <br /> O tio[Po Mat FA4 ; <br /> t <br /> N <br /> Co <br /> .:;e �'', �••+r ti CSG; .Y '� -ff�:i`-i .•r`.Sr i.� 1 <br /> � 15.SDe ial Handling Instructions and Additional Information <br /> ao <br /> F <br /> l tet) f=S Go Cr(,-C-�S �•uv <br /> 16.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and are In all respects in proper condition <br /> for transport by highway according to applicable International and national governmental regulations. Date <br /> Printed/Typed Name Signature Monrh Day Year <br /> O /& z 2 V- <br /> T 17.Transporter 1 Acknowledgement of Receipt of Matedals Date <br /> PrintedlTyped Na Signal <br /> Month Day Year, <br /> N <br /> - o ,18.Transporter 2 Acknowledgement of-Receipt-ofMlateg —Date <br /> - �°'" "—"'^"" -" <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19. Discrepancy Indication Space - <br /> F <br /> A <br /> c <br /> 20. tem ity Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted In <br /> 19 Date <br /> T <br /> Y Prl t Ijy Name Signa , MontA Day Yeer <br /> DHS 8022 A(11184) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS + '1 <br /> dcca R,n �2) To: P.O. Box 3000, Sacramento CA 95812 <br />