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epartment <br /> Health Services <br /> State otCailtornia—Health and Welfare AgencyToxiicc Substances fControl Division <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST LOA- 9 . B . 9.S Document�No <br /> nof lewnot required by Federal <br /> 3. Generator's Name and Mailin2_9ddress 1 A.State Manifest Document Number <br /> 84692984 -�D$ CNrP-41 A07 O'C, //�Sic• ( ! 6'j _4 S / S.State Generator's i <br /> 4. Generator's Phone Oy ) 2 �- -z=.,.,x,;,% <br /> S. Transporter 1Company Name 6. US EPA ID Number CState;Trattaplfrtp['¢•lp; , <br /> �ll�� ,¢ r. D.Transporteea;.Ptione <br /> 7. Transporter 2 Company Name 8- US EPA ID Number E:Stat r TranspMt9r'8 1D }` <br /> . F.7,tansporter'a:Pflone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number GState Facility' ID yrT� <br /> POOt� F�l14 CtI�S r'� IN L4 <br /> IAO &-,K H.Facy's Phone <br /> lllt3aS < 3s5' <br /> 12.Containers 13. <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total UnitWaste No: <br /> No. Type Quantity trop - <br /> G <br /> EnfvLLiYy�'i�/r�ff� WITS/� '•X%L.//�� /V�5 aF-�',`� .µ r�l'i : <br /> aF A <br /> 5%. b. <br /> T <br /> 0 <br /> C. <br /> d. <br /> O0 ddlt t p" z<I44 inp Jgt YJ�e as tial AbQ(9; <br /> t.V <br /> y N^ a• •" w :`t7'.'rT •�X�'c�.``' c� -. l ' � Tr✓-�n ::;v',. - x ��� °�"�'.. <br /> 15. Special Handling Instructions and Additional Information <br /> CO <br /> 16.GENERATOR'S CERTIFICATION:I 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 <br /> for transport by highway accords g to applicable IrllerltaUpnal and national govern ental r gulallons. <br /> ,tom T r-�Ie C r/f'c Date <br /> PrintediT yped Name Signature �- _ {� Month Day Year <br /> P �JJ <br /> T 17.Transporter 1 Acknowledgenneffit of Receipt of Materials Date <br /> a Prin /Typed Nam ®/ Signatu Month De Year <br /> Ns <br /> o 18. re s orter 2 Acknowledgement of Receipt of Materials Date <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> I <br /> i 20 Item it19.Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted In <br /> y <br /> Date <br /> T <br /> T Prl d/7yped Name Slgnat Month Day Year <br /> e 3 <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> DHS 8022 A(11/84) To: P.O. Box 3000, Sacramento CA 95812 0469641 <br /> (EPA,8700.22) <br />