Laserfiche WebLink
'--Sr3TF o!Camornla—Health and Welfare Agency • <br /> Department of Health Services <br /> Toxic Substances Control Division <br /> Sacramento,California <br /> . Please print or type. )Fo(m Designed for use on elite(12-pitch)typewrnar.) <br /> UNIFORM HAZARDOUS 1.Cienerators US tpA ID hic. Manifest 2.Page InformationinI a shaded areas <br /> WASTE MANIFEST t /� .< n mac% Do�ccument o. is not required by Federal <br /> )' /'� t e) - .O of law. <br /> nerator erre a d ailing dd�ss tete ani est Document Number <br /> � `��,r�,— � �.e�,,,sn/t/�:-,a �,��1. $4 0 519 7 <br /> '5 /lw AZ- >� W, 'i S-1 ZS 3.�/ B.State Generator's 10 <br /> 4. Generators Phone o?0 '] 3, <br /> ranspoger omp ame US EPA ID Number F to ransporters <br /> LCI)_S 1-99, ronsporter s hone <br /> rensporter ompany ame U EPA ID Number cpaler s <br /> tete ren 3 <br /> . . . . . . . . . . ramp srter s to <br /> signet eci Ity ame end Its ss US EPA ID Number <br /> o ox 330As� c Sa(a �Dl �D6 <br /> •s- ,e a �'a 1`�33�� .�� .7� 7 •(�/J��S}`3aS S3 Sf <br /> 11.US DOT Description(including Proper Shipping Name,Hazard Class, end/O Number 12.Contsiners 13. 14. <br /> Total Unit 1+` <br /> o No. T Ouantit Waste No. <br /> E a. <br /> E <br /> b. <br /> { 7 <br /> O <br /> a <br /> C. <br /> d. <br /> ove. . - I1t"C"for Wool" suave <br /> w _ t <br /> Is a Ing istructlons "and Additionaln ormatlon <br /> hereby dedere that Mecontents of this consignmerK are ullyand accurately described <br /> above by proper shipping name and are classified,packed,marked,end labeled,and are in all re <br /> transporty enacts in proper condition for <br /> by highway aceordi o applicable international n�atlio aal govern ntal r uletione. <br /> Print /Typed Name ^., <br /> "-1—�'�'U Date <br /> ('45; Signature Month Day Year <br /> T 17.Transporter 1 Acknowledgement e edgement of except of Materials Dste <br /> ' rinted(Zyped M No urs Oe s <br /> s 1iaL\� <br /> r <br /> _.--- oa_ TranaQrter 2 ACknowlsopemeh.t, or Aecsi a y <br /> ... ., PS_.... M.1o.lM► _..,_;,.. _:..,�.:., .-. . ,,.,;..- .... .:. : ,.":. ..Data, .._ ,. <br /> 6 Printed/Typed Name Signature <br /> a Month Day Yser <br /> 19.Discrelxncy Indication.Space <br /> F <br /> A <br /> C <br /> 1 <br /> l <br /> T 20.Facility Owner or Operator: Certification of receipt of hazardous materiels covered by this manifest except as noted in <br /> If hem 19. <br /> t any Date <br /> ' ^n W / r Month Y ser <br /> � cCJ <br /> HS$ou A(7/84) Whito: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> 96700-hj TO: P.O.Box 3000, Sacramento, CA 95812 w awl <br />