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Department of Health Services <br /> State of Califolnia—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 /> 1.Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS Document No is not required by Federal <br /> WASTE MANIFEST !� k� Of law. <br /> 3. -.Generelgr'a Name and Mallin Address. A.State Manifest Document Number <br /> l�fF -.'ra <br /> ,4) �f? `.�5. , J B.State Generator's ID <br /> V <br /> 4. Generators Phone( :') <br /> 5. Transporter 1 Com any Name 6. US EPA ID Number C.State.Transporter'a-.:ID' ,p <5! <br /> D.Transpotter's Phone^ <br /> 7. Transporter 2 Company Name 8. US EPA ID Number Estate Transporter's-,--] ��,r <br /> . F.Transporter's Phona', "=�;- 'T ' <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G.State facility's ID <br /> �n�/ cDc �FutN GUfiSr=r /uc <br /> H,Faclllty's Pribne *- ' <br /> 5�r��FFc_� 33s� ..qJ 1'.86, .P.7.4 . s 3aS s3s�' <br /> 12.Containers 13. 14. <br /> 11.US DOT Description(Including Proper Shipping Name,Hazerd Class,end ID Number) No. Type pTota <br /> l <br /> a it Waste NontI <br /> a f, <br /> a z2v?, <br /> j Ab <br /> T . <br /> 0 <br /> a <br /> C. <br /> d. <br /> 00 <br /> iPns3p[�Aaterlata' tfld ., antttny �� < I <br /> Ny tiAgae s k yKz <br /> 15. Special Handling Instructions and Additional Information <br /> 00 <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 acc 1 to applicable Int rr��gtional and napnal�ovgytmental regulations. Date <br /> X,� ���/ <br /> PJrinted/Typed Name Signatu Month Dee Year <br /> .D <br /> r 17.Transporter 1 Acknowledgement df Receipt of Materials L <br /> Date <br /> R PJr'Y�'-dlType am Sign Month Day Year <br /> N ` <br /> o 18.Transporter 2 Acknowledgement of Receipt of Materials Date <br /> R Printed/Typed Name Signature Month Day Year <br /> E <br /> a <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> L 20.Facility Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> I - Item 19. Date <br /> v PH tedlTy Nam Signatur Month Day Year <br /> 8' <br /> F <br /> White: TSDF SENDS THIS COPY TO DOHS WI IN 30 DAYS <br /> DHS SQ22 A(11180 To: P.O. Box 3000, Socromento CA 95812 <br /> (EPA 8700-22) , <br />