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• Department of Health Services <br /> Toxic Substances Control Division <br /> Stale of California—Health and Welfare Agency _ Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) an est 2. Page 1 Information n the shaded areas <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. ocum�t No is not required by Federal <br /> WASTE MANIFEST �• S 13• / of law. <br /> 3.f Generator's Name and Melfin _ <br /> ' A State Manifest Document Number <br /> B State Generator's ID <br /> G/f <br /> 4. Gen9ratoPs Phone( � ) - <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C.Stan Transp4heOA4 - / <br /> -LtL� D.TfansPoflet'&�tOt1� <br /> 7. Transporter 2 Company-Name <br /> g. US EPA ID Number E.State TmnsDorttir's #Digs-+.>i:' ," <br /> D . F.TransPorter's,.F,hone' fi,b <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G.Stg�ae.�Facility s Iq�,• i '*t`'S"^t $` ,_ <br /> 9, Designated <br /> ffeo[ E L(/A-5%f_ /NG <br /> H Facility s Phone <br /> / /7 <br /> ��j,t <br /> CA `� 3315'Sr 12.Containers <br /> Total Unit i <br /> 11.US DOT Description/Including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity NtlVo Waste No. <br /> NdS ooe*-F �. <br /> a <br /> s: T b. <br /> 0 <br /> a <br /> x= <br /> C. <br /> d <br /> CD <br /> Cfl <br /> Rtt 15. s cial Handling Instructions and Additional Information <br /> 00 rGl// C�PraJCE ye� 6/ <) <br /> Gl rrU S C-•o G GZ-C S - &0 %_S <br /> 18.GENERATOR'S CER7iFICATION:I hereby declare that the Oontenis of this consignment ale.- described <br /> lly end accurately <br /> -ked,marked,and labeled,and are In all respects In proper condition <br /> above by proper shipping name and are classified,pa <br /> for transport by highway according to applicable International and national governmental regulations. Date <br /> Signature Month Day Year <br /> IntedlTyped Name <br /> t 17.Transporter 1 Acknowledgement of Receipt of Maternais Monfh Dey'Year <br /> IPr d/Typed/j/1gme Sion <br /> :.._ <br /> ._ Date <br /> " 0 16.'Tranapaher 2 AcknowledgementorRecelpt-of'Materkl Month Day Year <br /> Primed/Typed Name Signature <br /> i a ' <br /> R <br /> 19. DlscrePancy indlcatlon SPece <br /> tarePS a f.oN T�.t Nkm e� <br /> Gepl: ort t d n,w», .� a r^e,1� o acct $� <br /> F Of CON 7Af NFrS So.�.�ca .-.rOadr 601 . <br /> C <br /> 20,i em Ity Owner or Operator.Certification of receipt of hazardous materials covered by this manifest except as noted In Date <br /> is sign e 3Nonit�Day Year <br /> v -.- ., /Typed Name9. .� - 0 . .. Y <br /> k� <br /> k White: TSDF SENDS THIS COPY TO DOHS WITHI 30 DAYS 9489641 <br /> AaoHss22A111ie!) To: P.O. Box 3000, Sacramento CA 95812 <br /> . EPA87p0.221 .. _ <br />