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• • Department of Healtn Services <br /> State of Cahtorma—Health and Welfare Agency Toxic Substances Control Division <br /> Sacramento,California <br /> Please pont or type. (Form designed for use on elks(I2-pitch)rypewrils) ani cal ego n Ormall0p i❑the she <br /> ed ar0a5 <br /> UNNI/PASTE <br /> MANIFEST OUS l�t�` S C� Documents o� 0} aWnot required by Federal <br /> eneretor a ame and ailing ddresS <br /> tale anifesI ument Number <br /> X4505198 <br /> fallf�� >4 �J B. tate eneretor s <br /> 4. Generator's Phone ( I Qy <br /> ransposler om�_ me U EPA ID Number ` tete rsnsportm s <br /> 5. Tran sporter 6 5 <br /> ID7. ranaponer ompany Name U EPA ID Number tats ransporter s <br /> . ransporter s no <br /> es(gnat aci ity ame en rteddr as U EPA I Number • <br /> //99 go6 � <br /> ltirr M.Facsl s rhorts _ <br /> !� 12.Contaimers of 1n <br /> 1. <br /> al <br /> 11US DOT Description(/n lC uding Proper Shipping Name, Haterd Class. and/D Number No. T e Quanti Unit waste No. <br /> E <br /> R <br /> rK A b. <br /> 0 <br /> R <br /> C. <br /> d. <br /> KMarNMing Codes for Waste U511413_ <br /> r <br /> g <br /> � e a 'fop netructfons a mono n ormamn <br /> er declare that tlrccntenno thiaccnsignmeMere ully sod aceuratelydescribed <br /> above by proper shipping name and are classified,packed,marked,and labeled,and mein all respects in proper condition for <br /> transport by highway according a 17Vinternational and national lictirernmennal regulations. Date <br /> 4 �" ��� Month Day Year <br /> Printed/Typed Name 'Q Signature �� D/ <br /> ,!/- Q, ��7Ff+� ✓� �d l Date <br /> T 17.Transporter 1 Acknowledgement of necelpt of Materials Month Dey Yeer <br /> A Printe4(Typed Name Signature , <br /> N - r <br /> s , -- Det ._.: <br /> 0 1ff<Trensportar 2 Ack - nt or Res--i-pt of Alaterlais' Month Day Year <br /> R PriMakt/Typed Name Signature . <br /> E <br /> R <br /> 19.Discrepancy Indication Spm* <br /> F <br /> A <br /> I <br /> I <br /> I 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T hem 19. Date4 y M1Yfe Month ay ser <br /> t (M ame W <br /> J <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> D1ier6022 A&/ee) TO: P.O. Box 3000, Sacramento,CA 95812 M wt <br /> (EPA 8700-22) <br />