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State of Callfornla—Health and Welfare Agency • • Department of Health Services <br /> Tonic Substances Control DIA,lon <br /> Sacramento,California <br /> Please pint or type. (Form designed for use on elite 112-0ach)typewriter.) <br /> UNIFORM HAZARDOUS enerators o arrest ape normationinthe shaded areas <br /> Document No. is not required by Federal <br /> WASTE MANIFEST G' -°S/ r' r of law. <br /> enerator 6 Name an ailing Address; tate ani eat Document Number <br /> �•/{ f� . T,. ,,� .. >. ,, , 84505101 <br /> B.State Generatore ID <br /> 4. Generator's Phone 1 ?^ `1 S- 7 C <br /> S. ranaporaerI Com—D-a—nv-Wanne US EPA ID Number C.Stabs Transporter a <br /> 7. Transporter company Name U EPA ID Number E.Ststo Trot,mpoRM.i .ID <br /> F.Transporter 0 PbW <br /> Designated Facility Name a Site ess U EPA I umber il <br /> r��, ,: 1�,/, ate , e9 <br /> Jac. � ny <br /> 3 3 ( e aal s Phone <br /> Aw-j 3.2 r- S Js' r <br /> 12.Containers 13. 14. <br /> 11.US DOT Description(including Proper Shipping Name, Hazard Class, and ID Number) Total Unit Waste No <br /> No. T Ouantit <br /> E a. <br /> E ,7 l c/,, fP .�;�, l3/ /vl� . _� /Y� Z �J ` <br /> R <br /> T C. <br /> 0 <br /> R <br /> C. <br /> d. <br /> ILH"uw - rot w st <br /> y <br /> y�} x e v <br /> pecla a Ing natruCtlons and moria n w—mation <br /> Z/ G- <br /> G/o Ve') Cd SP IBJ <br /> 16.GENERATOR'S CERTIFICATION:I hereby declare[that thecontionts of this consignmerK are fully and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and we in all respects in proper condition for <br /> transport by highway according to applicable imernetional and national governmental regulations. <br /> �uT Fi,re 0)" - 7-1/L.0 S Date <br /> Printed/Typed Name Signerur Month Day Year <br /> j <br /> ,F. <br /> T 17,Transporter 1 Acknowledgement of Receipt of MaterialsDate <br /> tedR Name lure <br /> Month Day Year <br /> a <br /> s <br /> v) <br /> 0 18. ronsporter 2 Acknowledgement er Receipt of Materiah '- --- - - .__ .....'_.Date_.- <br /> 7 Printed/Typed Name Signature Month Day Year <br /> E ' <br /> R <br /> 18.Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> 1 <br /> 1 20.Facility Owner or Operator: Certification of recaipt of hazardous materials covered by this manifest except as noted in <br /> T hem 18. Date <br /> v <br /> Pri <br /> nt anal gnat Monti may ear <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (EPA 0700-22) ox 9022-2(7/a{) TO: P.O.B 3000,Sacramento,CA 95812 w ew+l <br /> (EP <br />