Laserfiche WebLink
0 <br /> State of Calitornia—Health and Welfare Agency Department of Health Services <br /> Toxic Substances Control Division <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter) <br /> UNIFORM HAZARDOUS enerators o. Manifest ape noimationintheshadedareas <br /> WASTE MANIFEST Document No s not required by Federal <br /> �/9 ��r bO P y.t"�- / i 6 <,. law. <br /> Generator's ame an ailing Address tate Manifest Document umber <br /> 3. <br /> -Z �.�.r aY T r_ > . ��. , 7, -j 84505192 <br /> y _D- <br /> 4. Generator's Phone ((2 e) <br /> 5. ransporeerCompany Name US EPAID Number C.Stats, ransporters 7d6 <br /> . ranaporters <br /> 7. Transporter Company Name a ub EPA ID Number tate ransPli tKi ID <br /> F.Tratrusporters Friginq <br /> 4aignaivd Facility—ga—meand Site Address On rri I Number G.St L ft FacillPs' <br /> 33 ! 6 H.F*W'iW& <br /> ' 12.Containers 13. 14. <br /> 11.US DOT Description(Including Proper Shipping Name, Harard Class, and ID Number Total Unit Watts No. <br /> No. T Ouantity <br /> a. <br /> a <br /> 4 <br /> A b. <br /> T <br /> 0 <br /> R <br /> C. <br /> d. <br /> Hertd bV for atter <br /> t <br /> r t <br /> Special a l Instructions a ntorla n ortlr t-- <br /> 0 <br /> Pwl ���B.�T,� <br /> herebycleclarethatthecowritents ofthis consignment are fully and accurately described <br /> above by proper shipping name and are classified,packed,marked,end labeled,and we in all respects in proper condition for <br /> transport by highway sxord W ice international and national governmemel regulations. �AD�y <br /> rC C/fG-TeiPuS <br /> Printed/Typed Name S, re O MYear <br /> f3. /yI f!�, / , id .bio !i <br /> T 17.Tra1 Acknowledgernefitot Receipt of MaterialsDate <br /> Month Day Year <br /> A Pri yped Na Si to <br /> ;0^�19'Trsrtal7rttiY`4' A... `bT'r7Aipt tri'"' s - Oate. <br /> T Printed/Typed Name "Signature Month Day Year <br /> E <br /> e <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> I <br /> 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> zon <br /> T <br /> r hem 19. Date <br /> ntName gnat a - Month Day Year <br /> White: TSDF SENDS THIS COP TO DOHS WITHIN 30 DAYS <br /> CHS$022 A(i/e41 TO: P.O. Box 3000.Sacramento.CA 95812 - <br /> IrPA ar�e_ee. <br />