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Department of Health Services <br /> State of Celif6me—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 sha ed areas <br /> T Docum o. is not required by Federal <br /> WASTE MANIFEST /L2 ` ?SL `1> of law. <br /> 3. ,Generator's Name and Mailing Addr� _ A.Stete Manifest Document Number <br /> J <br /> 9(-$ f-rs eAt.] �L/� rl1 U�='-5✓O� ��Q %�} ' B.State Generator's ID <br /> 4. Generator's Phone( 4.J — - <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C.State Transporter's ID <br /> SZ- �lr!,Ci.(J c 9. D.TranspoW.a Phone',,Nos, <br /> 7. Transporter 2 Company Name & US EPA ID Number E.State-Transporter's ID :,,;, <br /> F.Transporter's Phone - <br /> 9 Designated Facility Name and Site Address 10. US EPA ID Number G.Staie Facility's ID - -' <br /> :� l �LY/Lt lt/ASi�- �AJ( /il OliZz'l <br /> n QL)K 33G.b H.Faclllty's Phone - - <br /> ff 7,a.,. �1; �.7 . VDs 3 a.ss 3 SS'". <br /> 12.Cont, ners 13. 14. t. <br /> 11.US DOT Description(including Proper Shipping Name,Hazard Class,end iD Number) Total Unit Waste No.. <br /> No. Type Ouanti ty t;voi <br /> c <br /> E a. L/Gl tii.v S E 'd/'C <br /> E <br /> R <br /> T b <br /> O <br /> R - <br /> C. <br /> d. <br /> CD <br /> ItloOalOeacrfp}10n aterlab=lJattldpgK6' }{anciling fof49iaatesli`tedA ve - <br /> � 4s � .� t 5 <br /> CV y r <br /> z <br /> 15..Special landling Instructions and Additional Information <br /> S ,1�ae-rat's 6ea%S <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 accord 9 a placable Internationaland natignal gover regulations. Date <br /> Tiii d h7V— <br /> PriWedlTyped Named� Slgnatur Month Day Year <br /> IF b <br /> 1 17.Transporter 1 Acknowledgennerit of Receipt of Materials Date <br /> PrintedlT p d Name Signat Month Day Year <br /> a �� QCT-Gly- <br /> --:- P _. _ .. Dale <br /> 0 18.Yranaporter 2 Acknowledgement of Receipt of Materials <br /> 4 Printed/Typed Name Signature Month Day Year <br /> E <br /> e <br /> 19. Discrepancy Indication Space <br /> F <br /> C <br /> 20.Flit Owner or Operator:Certification of receipt of hazardous materials covered cept as noted In <br /> 1199 Date <br /> yPrintedlTyped me Slgnatu MontrhDay Yeer <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> - DHS e022 A(11ie4) To: P.O. Box 3000, Sacramento CA 95812 e.eeaa <br /> (EPA 6700-22) <br />