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• <br /> State of Calltornia—Health and Welfare Agency Department of Health Services <br /> Toxic Substances Control Division <br /> Sacramento,California <br /> Please print or type. (Form eeaigne0lor uce on elite(12-pitchl typewriter.; <br /> UNIFORM HAZARDOUS enerators o. O p�Manifest age Information In the shaded areas <br /> MANIFEST 1T p 0 �` 5- <br /> WASTE ) / V 1 u��CN o1 iawnot required by Federal <br /> :i ernerator s amand mailing tate Manifest Document umber <br /> 411,17 "-f" <br /> 84505194 <br /> t 7, Kre S1'3�' r tete enerators 10 <br /> 4. Generator's Phone (jv <br /> renspoteer its ame U EPA ID Number . tete ransporter s <br /> D.e F 3 .O.n.3 6 .y `J . rartaportar sI't"- <br /> 1. <br /> dorJ y S5G6 <br /> transporter 9 toornigarl US EPA ID Number E.Starts Transporter-9 <br /> renspatsr• Phone <br /> 9. Designated Facility Name and Site Address us EPA ID Number rlSpiaFiscil • 7 f,7 7` <br /> I�7 /.� G✓� �� 5� . CHID 5�� 6 <br /> Imo'J. �S DY y�J L C acilty t Phone <br /> 12.Containers 13. 14. <br /> 11.US DOT Description(including Proper Shipping Name,Hward Class,and ID Number Total Unit Waste No. <br /> g No. T Quantity <br /> N a/ .1 Q/) 141 <br /> AT <br /> y T b. <br /> 0 <br /> a <br /> C. <br /> d. <br /> Above KHant"Codas for Warns <br /> f i � <br /> 15.SpecialH Handling nstructans a diene n armetion <br /> 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 in proper condition for <br /> transport by highwayso�r d�ing to applicable Int national and natipnal governmental regulations. <br /> /1rz.�f'AjT ' �dc 72!i ��.c/3 Date <br /> Printed/Typed Name Signety� Mouth Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> or <br /> Printed/TName Signature Monrn Day Year <br /> :. , ..-�. .. <br /> -. .rk .9:&iransgorter:.d'- 7+otigety�'ems�S-or e p ` fir': - .. ...l5ata . <br /> T it <br /> Printed/Typed Name Signature Month Day Year <br /> a <br /> 19.Discrepancy Indication Spew <br /> s <br /> c <br /> C <br /> 1 <br /> l <br /> 20.Facility Owner or Operator: Certification of receipt of henrdous materials covered by this manifest except as noted in <br /> T hem 19. <br /> T <br /> Date <br /> t ame / p car Month Day Year <br /> ct/Lrsr,c.t hAla iy <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> DHS 0022 -2(7/84) TO: P.O. Box 3000, Sacramento, CA 95812 <br /> (EPA 0700-22) 84 aW1 <br />