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0 0 <br /> State of CalitFrnia—Healtn and Welfare Agency Department of Health ServicesToxic 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 1 Information in the shaded areas <br /> WASTE MANIFEST -� I Document No. of lawnot required by Federal <br /> 3. Generator's Name and Mailing Address / A.State Manifest Document Number <br /> Cl .' LIl'V . be D i`. <br /> 968£-x1-ce14L b Atli mv6J4 qS 3��� BState Generators ID <br /> 4. Generator's Phone <br /> 5. Transporter 1 Company Name 6. US EPA ID Number CStetl;;giallilpol'Iel?-A€ <br /> U c9$ 3 t?O . D.TrenepDtYe1 a,-Ph s ` <br /> 7. Transporter 2 Company Name 8. US EPA ID Number ESta'te"7ffiRBpOrteB. <br /> . <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G State-F 11 BID <br /> ?,4_'.T fG l 4-o 1r , w a-Sf4 11V& <br /> H.Factit a Phone <br /> L.fr- o *7.5-2 <5 <br /> 11.US DOT Description(including Proper Shipping 12.Containers 13. 14 l <br /> p ( g p Aping Name,Hazard Class,end ID Number) Total umt <br /> G <br /> No. III Type Quantity Wrivo .Waste No. <br /> N a'tI/t Z A 1C U7 1-c5 w X574 i /Zc-3 s <br /> E <br /> R <br /> C. �/ .�. <br /> r " b. <br /> T <br /> 0 <br /> R <br /> C. <br /> d. <br /> 00 +� .�) � �DeBcd ftRe< _ K.+�andUnp Codes tq[Waetee �+baae <br /> T a <br /> Co Java <br /> 'Cr 15. Special Handling Instructions and Additional Information <br /> °O e e a- <br /> 16.GENERATOR'S CERTI CATION:I hereby declare hat 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 ylp,N aonlic ble I rn 'onal d ational_goy>3rr}men�al regulations. Date <br /> Printed/Typed Name Hfztti Slgnatur TiC/F-+C[.O Month Day Y ar <br /> T 17.Transporter 1 Acknowledgemertir of Receipt of Materials Date <br /> R <br /> PrintedlTyped Name Sig VMonth Day Year <br /> " <br /> p dna c� AJ <br /> 8 <br /> _ <br /> ' 0 18.Transporter 2 Acknowledgeman oof Recelpl of Materials Date <br /> R <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 /> � 20.FacllltYy Owner or Operator.Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T Item 19. Date <br /> L71ntedffy Name Signature Month Day Year <br /> DHS 8022 A(11184) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS o <br /> (EPd8700-22) <br /> To: P.O. Box 3000, Sacramento CA 95812 8489641 <br />