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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 /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST ,) �'�) . ' .5 Docume t of is required by Federal <br /> law. <br /> 3. Generator's Name and Mailing Address A State Manlfe t Document Number <br /> „c�x84692983 <br /> g State:,G neratoll to <br /> 4. GC <br /> enerator's Phone 1 1 —+ , € " TMe '£ " <br /> �, � '� ?�s�.��`�'-o. <br /> 5. Transporter 1 Com .Name 6. US EPA ID Number C'Statt.,Tf"e *1C ,Q �. <br /> L �if'F' lz2 ,6 C��3. 3 n?r�inppo gr s 3 <br /> 7. Transporter 2 Company Name 8. US EPA ID Number <br /> . . <br /> 9. signated Facility Name and Site Address to- US EPA ID Number <br /> fO OX .336 G' - _ iF�ecll(C— <br /> tfeafhof­*!s <br /> 12.Containers 13. 14 <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total Unit ' 1(VBStetlo ' <br /> No. Type Quantity tNo <br /> G <br /> E <br /> i <br /> E , S <br /> R <br /> T b. <br /> C. <br /> !� 1L� �Y`yiA <br /> . KI '43 <br /> CM <br /> 00 s Lie3e0 A,__ e <br /> CV <br /> C.C) <br /> q4' 15. Special Handling Instructions and Additional Information <br /> 16.GENERATOR'S CERTIFICATION:1 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 Inter tional and naa��IIonal governmental regulations. <br /> —d /iG— .C"A.cfS Date <br /> Print d/Typed Name Signal ` C Month Day Year <br /> N <br /> T 17.Transporter 1 Acknowledgement f Recelpt of Materials Date <br /> A Printed/Typed Name Signature Month Day Year <br /> N b <br /> s a <br /> o 16.Transporter 2 Acknowledgement of Receipt of Materials Date <br /> T Printed/Typed Name Signature Month Day Year <br /> E _ <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> IL <br /> Item <br /> Owner or Operator.Certification of receipt of hazardous materials covered by this manifest except as noted In <br /> T 199 Date <br /> Y ed Name Slonere 'Month Day Year <br /> Pr <br /> ��� <br /> DHS 802Y 01164) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS $4891141 <br />