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Department of Health Services <br /> State of Calif ctma—Health and Welfare Agency Toxic Substances Control Division <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite 02-1311ch)typewriter.) <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Page 1 Information In the shaded areas <br /> WASTE MANIFEST DocurrN . 0f is not required by Federal <br /> law. <br /> 3. Generator's Name and Mailing Address A State Manifest ocument Number <br /> ciff) .t4 Do r, «as�o1-���;�1� _ _ 8 69 �8 <br /> G d! ei+1 7�L G A�� �5 to,QerYe tops ID f s <br /> 4. en ator s one( ) <br /> 5. Transporter 1 Company Name 6. US EPA ID Number Q. fr 76 P. f•. l <br /> LG <br /> O.T1aAaPofteY tone; LL <br /> 7. Transporter 2 Company Name 6. US EPA ID Number IMA <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number <br /> PA ty'>;'Pt <br /> 12.Containers • ri13. 14 Unit <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class,and ID Number) No Type puantity <br /> G �,- <br /> E a. E 4 <br /> E ja h2ArDdt 5SaLj nZ'S oft OD 0✓S <br /> R <br /> A b. <br /> T <br /> N ;..,. <br /> w[+ <br /> C. <br /> d.Ln <br /> 00 <br /> Y . <br /> adn au x�g t ,ls t� ry ; „ .A. i nq . sresteeatea <br /> 7v�•.n Y. �—Y t [ t�2 <br /> 15. Special Handling Instructions and Additional Information <br /> 16.GENERATOR' CERTIFICATION:I hereby dacla 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 applis@z Internal a0d_(tat net n.mentvl rggyiatii a. Date <br /> Prin Typed Name rll Signal <br /> /Y-L�/•��f� Month Day Peer <br /> Date <br /> T 17.Transporter 1 Acknowledgement of Jillecelpt of Materials <br /> A ;Zcknowledgement <br /> N e Slgn Mon h Da Year <br /> N <br /> - 1.4l �7 -y = -- <br /> 0 18. of Receipt of Matelots Date <br /> T Printed/Typed Name - Signature Month Day Year <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> r <br /> C <br /> 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 /> t._ T Month Day Year <br /> t#� y PrintedlT ad arae Signature <br /> 3 ie <br /> a r' <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> DHS 8022 A(11I81) To: P.O ox 3000 Socromento CA 95812 <br />