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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 412-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> - WASTE MANIFEST 7 i)- 'i -< -1:L DocumG 11J� 01 Is required by Federal <br /> 3, Generglor's Name and Mailing Address A.State Manifest Document Number <br /> I rr <a, srk5ne r'c �L•/�, / 9 <br /> �y( o IIZi:'F'—Ai_ir] ✓l� rb�/OI�F ( +4 r/ B.State Generators ID <br /> 4. Generator's Phone( 5.7 <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C.State,Transporter's tp:`. <br /> ` &14 < lD.Transporter's Phone' <br /> 7. Transporter 2 Company Name 6. US EPA ID Number E.State Transporter's ID <br /> . F.Trdnsportar's.Phone <br /> 9. Designated Facility Name a/n�d Site(Add as 10. US EPA ID Number G.5tate Facility's ID - <br /> r.Gl /'t`•X 3,76 k H.Facllity's Phone ' <br /> 12.Containers 13. 14. ,.1_._.. <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total un't Wast e No. <br /> No. ITypel Quantity hIlvoll, <br /> G <br /> E ay � <br /> E .•.Z+01'-411'S lZ'14 S <br /> R J.: <br /> J: T b. <br /> O d. <br /> R <br /> C. <br /> d. <br /> oddilionp! ,�,sto�:tor ateriald <br /> Cil E ° -r'f�£ t � n " _ .. •! <br /> 15. Special Handling Instructions and A ditional Information <br /> 00 ccC 7,4rc G�8/ <br /> �llrbl-� S Gl�v <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 acco i to ap.Plicable International and national overnment I regulations. Date <br /> P c/Sg <br /> Printed/Typed Name Signatu Month Day Year <br /> T 17.Transporter 1 Acknowledgement of acelpt of Materials Date <br /> A Pr to yped Na u Month Day Year <br /> ✓ /mr7�w � - — 0 b <br /> I, <br /> 18.Trandporter 2 Acknowledgement of Receipt of Ma Date <br /> AT Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 20. acillity,Owner or Operator:Certification of recelpt of hazardous materials covered by this manifest except as noted in <br /> I Item 11 Date <br /> v Printed/Typed Name Slgnat re Month Day Year <br /> F l Oro A,)/J Q <br /> J <br /> DHSP022 A(11184) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS a4eva�t <br /> (EPA 87D0-22) To: P.O. Box 3000, Sacramento CA 95812 <br />