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State of CalHornla—Health and Welfare Agency Department of Health Services <br /> TOXIC Substances Control Division <br /> Sacramento,Callfornla <br /> Please print or"I" IFwm deli ned fw use on elite(12-pitch)hpawrita.) <br /> UNIFORai ROODS 11.Generators LIS EPA ID No. Manifest 2.Page 1 normationinthe shaded areas <br /> WASTE MANIFEST l S $ ° °Ij"P9t of 1aw"dt law. by Federal <br /> rerw fors name a Mailing rens 1 A- tate Manifest Document umber <br /> AeI rr,° of— (0b,"s 1-04 71-10-70 84505188 <br /> �08 F/1lf('AG/� r�L/� �fOG of QS3-? B.State Generators <br /> 4. Generator's Phone 1 S �'" 4 - <br /> renspofsar ompeny ame U PAI Number jar snap:;; r <br /> :r4l� 8 -4/3•V <br /> Transporter7. <br /> ny ame P Com umber rfseponart <br /> . . . . . rensport s. <br /> as gnat Alii[y Name an Site Address 1 umber astaft ,t,., <br /> P��oLLFURA Q/A-5 F- /,4J C_ c- <br /> 0 <br /> 0 Box 336 <br /> . .a e Phone <br /> 25 �'i s� �} 8 5�4-7�/ <br /> 12.Containers 1 14. - -: <br /> 11.US DOT Description(Including Proper Shipping Name,Ha:ard C/ass and ID Number Total Unit wall"No. <br /> a No. T Ouantitv <br /> E a. <br /> 114;,4ej�eu_S Lufts.' S°ups u o.s aQcu -� O� Y /� w <br /> A <br /> ° T a t <br /> e <br /> R <br /> C. <br /> d <br /> Lmanmirq codas tar wa.oa. <br /> file <br /> 4 <br /> y <br /> pecta Handling Instructions and Additionaln ormstson <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 mein all respects in proper condition for <br /> transport by highway according 10 applicable international and national governmental regulations. <br /> Date <br /> P "nted/Typed Name Signature Month Day Year <br /> Z <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> N _Esjnted/Typed NSig rs/ Mo n De Year <br /> No <br /> NMY ame 1. 1 0 <br /> 0 18.Transporter 2 Acknowledgement or Receipt of Materials - Date <br /> T Printed/Typed Name Signature Month Day Ye&r <br /> E <br /> R <br /> 19.Discrepancy Indication.Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> T 20.ha iliil Owner or Operator: Certification of receipt of harsrn materials covered by this menifgat except as noted in <br /> _ y 19 Dau <br /> q rMonrh vely Toar <br /> t. 1 <br /> White: TSDF SENDS THIS COPY-TO DONS WITHIN 120 DAYS <br /> t; DHS 8022 A(7)841 TO; P.O.Box 3000, Swro nento,CA 95812 a <br />