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State of.California—Health and Weller:Agency Department of Health Services <br /> +, Tonic Substances Control Division <br /> Sacramento,California <br /> ' Please print or type. (Form designed for use on ellte(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest 2. Page 1 In rmat on n the shaded areas <br /> WASTE MANIFEST l . ?/ Documgpt of Is not required by Federal <br /> N law. <br /> 3./JGenerator's Name nd Mailing Adds A.State~(Vlenlfest•DOcument Number <br /> 9L�1� 4Lr� fl U��Si�t� (7,< C�S3S/ e tate C+anerat � z <br /> 4. Generator's Phone( ) a + <br /> 5. Transporter 1 Cody Name & US EPA ID Number <br /> 7. Transporter 2 Company Name & US EPA ID Number 5 ' <br /> . fi. <br /> 9.,P esignated Facility Name and Site Address 10. US EPA ID Number <br /> P.o ox 334,P Fay I+ty • <br /> 4 R5 PF I-I C7-3 3V I?A, U• 7-S <br /> / 12.Containers 13. 14 1 '�aer <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and/D Number) Total Unit f� <br /> a No. Type QuantityWt/Vo - <br /> a ���[)6LIS lul4�i f .�iV t,l,`> �•DS_ (�'rU—� 4 <br /> E O L /O <br /> T <br /> b. <br /> O <br /> R <br /> C. f <br /> rye[ <br /> v <br /> d. <br /> LO - <br /> O <br /> I d <br /> Cn �. <br /> a CV <br /> CD <br /> qql 15. peclet Handling Instructions an�ddltlooal Information <br /> 00 <br /> 6, �_S <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.ln proper condition <br /> for transport by highway according to applicable International and national governmental regulations. <br /> Date <br /> Printed/Typed Name Signature / Month Day Year <br /> Printed/Typed Name —7 <br /> k- S r o-li•e�l? -y -Z <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> A Printed/Typed Name Signature Month Day Year <br /> N <br /> 8 <br /> F .. .....-.. _ ._ - <br /> ' a 18.Transporter-2.Acknowledgement of Receipt of Materiels - - - - Date <br /> T Printed/Typed Name Signature Month Day Year <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 20. Item lty9 Owner 0r Operator.Certification of receipt of hazardous materials covered by this manifest except as noted in ' <br /> T 1Date <br /> r Prin yped Name - _. Slgnature -:Month Day04r� Iii <br /> -`Year <br /> ' 1 <br /> White: COY TO DOHS WfTHIN e4eos4i <br /> .DHS 8TSDF SENDS THIS 3A DAYS <br /> 022A(t1/e1) , - <br /> {EPA 6700-22). . TOC F.O. Box 3000, Sacramento QA '9' T'Z, <br />