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-$' Department of Health Services <br /> State of California—Health and Welfare Agency Toxic Substances Control Division <br /> • Sacramento,California <br /> Please Drinl or type. (Form designed for use on elite(12 pitch)typewriter.) <br /> UNIFORM HAZARDOUS 11. Generator's US�E-yPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST is ,.q .`. �� Document No. or law�ot required by Federal <br /> 3 Generator's Name and Mai ing Address A.State Manifest Document Number <br /> - 84692987 <br /> m5 �i.'7T,E'.q�-� ��c� c.s�+ 41- S / 9.State.Gene oes to �i <br /> 4. Generator's Phone ac <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C.State'Transporter's: <br /> D.Transpprter'a'PAgnev,. �> <br /> 7. Transporter 2 Company Name 8. US EPA ID Number £.Stet@TfahBpOttl�i'IDrvf ,xr; <S� •;> <br /> . FTravispDrlaPa'Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G fitata`Facility 10 <br /> H Facl� one <br /> A e s c a -3 3 i, �,4c�.9.�U . 7s'a � <br /> 11.US DOT Description I cludin Proper Shipping 12.Containers 13. 14 '�„1• . <br /> p ( g p Aping Name, Hazard Class,and ID Number) Total 14. <br /> e No. Type Quantity uvo ;.11118stf3`Nor <br /> E a. _ <br /> " '� i��CIJ llJ�rS�1 � t_�i:i AlC S �i '!L% �L s <br /> T <br /> C. <br /> d. <br /> Opoa a. ' }adoK <br /> t ns { <br /> O7 i -c�3o-uy •- i�. xr flu r- <br /> Cp ar <br /> 't 15. Special Handling Instructions and Additional Information <br /> 00 <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 accordjQg to applicable International and Rational govern r�8ntaregulations. <br /> � Date <br /> /!� �� l <br /> Printed/Typed Name Signatu�y Month Day Year <br /> .17 <br /> T 17.Transporter 1 Acknowledgement of ceipt of Materials Date <br /> A Printed/Typed Name gnat re Month Day Year <br /> N �T w1 <br /> 0 18.Transporter 2 Arcknowledge' nt of Receipt of Materials Date <br /> R <br /> T PrintedlTyped Name Vignature _ Month Day Year <br /> ir <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 20.Pe�llty <br /> Owner or Operator.Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T 119. <br /> Date <br /> YPrints yName Signature Month Day Year <br /> s <br /> r <br /> DHS 8022-2(11184) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS EPA 7 - O: e4 89611 <br />