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Department of Health Services <br /> State of California—Health and Welfare Agency Toxic Substances Con!,ol Division <br />.. Sacramento.California <br /> Please print or type. (Form designed for use on elite(12 pitch)typewriter.) <br /> 1. Generator's US EPA ID ND aN est 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS / Docum n No. s not required by Federal <br /> WASTE MANIFEST 01 law. <br /> 3. Generator's Name and Mailing Address A.State Manifest to <br /> Number <br /> Lt/}Lr r Dt/'r fir' l��h'3�c�4'T.rT, •„ 84692989 <br /> Atli �, ,D� �r� x-A c�5_3i__) B.State Generator's ID <br /> 4. G/eneraifSr�s« o e( �Y ) r� '' <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C.State This <br /> 16 <br /> .L �J� . . :7 12D.Trensporler"S Phone. <br /> 7. Transporter 2 C mpany Name 8. US EPA ID Number E.Slate Trensptxter's ID <br /> 6 - <br /> . . . F.Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G.Slate Facility's ID <br /> it✓i � «w LUA;5T£ iNL <br /> H: acility's Phone' <br /> ) <br /> 12.Containers 13. 74. I <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Unit <br /> Waste No. <br /> d <br /> E a. <br /> N � <br /> R �: 1L- 0 Oa Or <br /> A b. <br /> T <br /> d <br /> R <br /> C. <br /> d. <br /> - �- KHam111ng Codes for Wasted�ste{i Above - <br /> 00 J '-Additlfo{net Dge�scriptionss forMaterialsk1sted Above `�� t/+.�,t; , t, .��; t, ,,;.. r ._ s Po T <br /> W _ ✓F 3A^ '.a4� i NS�q^'�y .l , F V .p y <br /> *707 <br /> LD <br /> 15. Special Handling Instructions and Additional Information <br /> tb �GGe � i,� y+�Lelrl Fsl <br /> f - <br /> 16.GE ERATO 'S CERTIFICATION:I hereby dt�are 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 <br /> for transport by highway according o pplicable international and net n governmeAl regulations. Data <br /> V, <br /> L Tl'" N' Month Day Year <br /> PTlnte Typed Name Signatur � <br /> 7 4 <br /> n� JE k Date <br /> T 17.Transporter 1 Acknowledgement of eceipt of Materials Month Day Year <br /> Pri (Typed ams Sign <br /> a <br /> .Date <br /> P 1B.Transporter 2 Acknowledgernent of Receipt of Meter) Month Day Year <br /> i <br /> Printed/Typed Name Signature <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> 20.Facilityy Owner or Operator:Certification of receipt of hazardous materiels covered by this manifest except as noted n <br /> I Item 19. Date <br /> Dey <br /> IF Pri dlTy ed Name Signat <br /> Month Year <br /> _V41 V)AK2 <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS 8489641 <br /> DHS 8022 A(11184) TO: P.O. Box 3000, Sacramento CA 95812 <br /> (EPA 8700-22) <br />