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• • Department of Health Services <br /> State of California—Health antltare A ency Toxic Substances Control Division <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) ani est 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Docum o. is not required by Federal <br /> WASTE MANIFEST � of law <br /> 3. Generator's Naa[[nme-a d Mailing Adores telb.Mani t Documant.Nufnber i <br /> AAX t. <br /> gD8 u�RA[e7 A kf JEs7b 6A <br /> 4. Generator's Phone( ) <br /> EPA ID Number <br /> 5. Tran orter 1 Company Name 6. S <br /> � `' � SEP-vrc�:s x cj. <br /> 7. Transporter 2 Company Name 6. US EPA ID Number <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Numbar <br /> ?}� <br /> - <br /> o f3aX 334 3 <br /> 12.Containers Total Unit <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity tivo0' <br /> Nd�atAus <br /> A <br /> r o _; <br /> R <br /> J <br /> d. <br /> O <br /> t 00 <br /> N <br /> Cn Tr ' <br /> 't15.Special Handling Instructions nd A itional Information <br /> CO �c F 94 <br /> is <br /> 16.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accuratety 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 ac ording to applicable intern tonal and national overnmpntal regulations. Date <br /> PrintedlTyped Name Signature Mont Dey Year r <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> Printed/Typed Name Signal _ <br /> Month Dey eer <br /> R _ ___" <br /> :-.. ..: . _ .: .,�. ... 'Date._ . <br /> 0 15. ! anspor or 2"3,C7W:owfelQe.^.:..mt of 9666 Pt c! 1 c <br /> t Printed/Typed Name Signature Month Dey Yeer <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> ,' 711 <br /> jiqr, <br /> tor:Certiflcatlon of receipt of hazardous materials covered b a manifest except as noted In Date tT Month Dey Yeare - SI re <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> DHS 8022 A(11164) To: P.O. Box 3000, Socramento CA 95812 _ B4°B6r' <br /> (EPA 8700-22) <br />