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0 0 <br /> i f��3vO <br /> State of California—Health and Welfare Agency Department of Health Services/. Toxic Substances Control Division <br /> J�Y Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pltchl typewriter.) <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Paget Information int a shad areas <br /> WASTE MANIFEST ,, x .1 t x Docum t N bt Isawnot reQuiretl by Federal <br /> 3. Generator'same and Ma lln /Ad^dress <br /> 908 <br /> 4. Generator's Phone <br /> 5. Transp or 1 Company Name 6. US EPA ID Number <br /> 7. Transporter 2 Company Name 8. US EPA 1D Number <br /> 9/.� Designated Facility Name and Site Address 10. US EPA ID Number <br /> j£i�OCftllDt U/,a5� l.t>C, <br /> PC Lox $3l�G <br /> A�,Qs a <br /> 11.US DOT Dascri tion Includln Pro er Shi g 12.Containers 13. 14. <br /> p ( g p ppin Name,Hazard Class,end ID Number Total Unit <br /> 0 <br /> No. Type Quantity tivo <br /> E a. <br /> N t)�IISN' 0 5 c?�rcf-� <br /> E <br /> Q C—/ . . ./ C <br /> T b. <br /> 0 <br /> R <br /> C. <br /> d. <br /> r � <br /> N <br /> IT <br /> co <br /> 15.Special Handling Instructions and Additional InformationCo <br /> ' <br /> 16.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and are In all respects In proper condition <br /> for transport by highway according to applicable International and national governmental regulations. <br /> Date <br /> Printed/Typed Name Signature Month Day Year <br /> - t' � •-c-r� t/f <br /> cknowledgement of Receipt of Materials Date <br /> X.Transporter I A <br /> ` s_ Inled/Typed qame Signal . - Mpntif DDay, rear <br /> e 18.Transporter 2 Acknowledgement of Receipt of Materials Date <br /> -T PrintedirTyped Name Signature - Month Day Year <br /> In <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 20.Its ilmllty Owner or Oper r.Ce fl tion of receipt of hazaNpus materials vered by nlfestAxcept ae noted In <br /> t 799 ''•- Date . <br /> " r - PrintedR . <br /> yped Na Slgnatu Mo th Day Year <br /> i8022A'(.' ' <br /> ----rt <br /> -DAYS <br /> White:TSDF.$ENDS THIS COPY T DOHS WITHIN 30 -+. <br /> 111M) ,. _ <br />