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State of Califbrnla—Health and Welfare Agency• LT 3� Department of Health Services <br /> B rJ Toxic Substances Control Division <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) Sacramento,Cailfornia <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest 2.Pape 1 Information in the shaded areas <br /> j 1, WASTE MANIFEST �Q l Docum n�Np1 is not required by Federal <br /> of law. <br /> 3. Generator's Name and Mailing Address _ A.State Manifest Document Number <br /> s /_ ,—, o-�. b`f /'n�_, „( _ 86518220 <br /> O�/ `(fZv£-,PA -,), rQ-V L 1410 sc i( ' �i� �� 5 E.State Generator's ID <br /> 4. Generator's Phone( ) �� G j <br /> 5. Transp/ �S (� U9c er 1 Company Ne a 6. \ US EPA ID Number / C.State Transporter's ID7o3 3 — <br /> T—J • ! ! u/C y / O.Transporters Phone'7 <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E.State Transporter's ID <br /> F.Transporters Phone <br /> 9. Designated Facility Name and Site Address to. US EPA ID Number G.Slatq Facillty's ID <br /> P�- �1 z(//Lt W,4 /tip O� �` 6 <br /> P O 80,K 3 3 6, �, H.Facility's Phone <br /> 12.Contalnem 13. 14. 1 <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class,and/D Number) Total Unit Waste No. <br /> No. Type Quantity Wt/Vol <br /> a. <br /> N !'^ ��">'' (�� ) WA'S�L/ �L—�/�_J N6 / Y�l <br /> E <br /> R <br /> A D. <br /> T <br /> O <br /> R <br /> c. <br /> d. <br /> J. Additional Descrlptlons for M/ � <br /> Materials es ls Listed Above K Handling Codfor Wastes Listed Above <br /> Nso�i/v <br /> 00 <br /> 15.Special Handling Instructions and Additional Information <br /> 0) 4'rd is <br /> 16.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately deacr above y <br /> proper shlpping name and are classified,packed,marked,and labeled,and are In all respects In.proper condition for transport by highway <br /> according to applicable International and national government regulations. <br /> Unless I am a smell quantity generator who hes been exempted by statute or regulation from the duty to make a waste minimization certification <br /> under Section 3002(b) of RCRA, I also certify that I have a program In place to reduce the volume and toxicity of waste generated to the degree I <br /> have determined to be economically practicable and I have selected the method of treatment, storage, or disposal currently available to me which <br /> minlmlzes the present and future threat to human health and the environment. <br /> Printe yped Name Signature q Month` Day Year <br /> \)01 '�� / DY 401;11 SIZ <br /> T 17.Transporter Acknowledgement of Recelool Materials <br /> R Month Da Year <br /> A Printed/Typed Nagle Signature Y <br /> N <br /> a J 0 <br /> P <br /> 0 18.Transport r 2 Acknowtedgement of Recelpt of Materials CZ <br /> T PrintedfTyped Name Slgneture Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> I <br /> L <br /> T 20.Facility Owner or Operator. Certification of receipt of hazardous materials covered by this manifest excep s noted In Item 19. <br /> Y Month Day Year <br /> a /ed/TY Nape Sig i <br /> DHS 8022 A(11185) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (EPA 8700-22) To: P.O. Box 3000, Sacramento CA 95812 <br />