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. . <br /> State of California—Health and Welfare Agency Department of Health Services <br /> Toxic Substances Control 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 IDN Manifest 2. Page 1 information n the shaded areas <br /> WASTE MANIFEST Docum of is not required by Federal <br /> law. <br /> 3AGenera)g 'sl�am nd Mallin dA6A8tgt0.MenMeSt Doc <br /> I4 UtrAggt NU PE Ig <br /> 4. Generator's Phone <br /> 5. Transiter 1 Company Name 6. US EPA ID Numb r <br /> E2 /Gl:_ 9Fs/ 3a <br /> 7. Transporter 2 Company Name 8. US EPA ID Number ' TranpOrf <br /> 9. Designated Facility Name and Site A dress 10. US EPA ID Number "� a <br /> s3 ------------ k <br /> 0-2 <br /> 3 y <br /> 12.Containers 13. 14 <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total Unit <br /> e No. I Type Quantity tvvo y1 <br /> R (J <br /> A b. <br /> T <br /> O <br /> C. l..T. . <br /> d. <br /> 00 1 <br /> 00 <br /> 00 <br /> "t 15.Special" Handling Instructions and additional Information <br /> 00 "-r4KJ� 46-);5-1 <br /> Q-OVFS - - ,Boors <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 acc rQQiIng to applicable Internatiogqal"�and national governmental regulations. <br /> G95uT &ore Pi9•Uj Date <br /> _0Tlnte�glTypeName Signal ule Month Day Year <br /> 4 D. /,7i�l� ae SSG+ 1KD. �1Si <br /> T 17. Transporter 1 Acknowledgemerif of Recelpt of Materials 61 Date <br /> R <br /> A Printed/Typed Name Sign atur Month Day Year <br /> IN !!11 <br /> PV <br /> -6 18.Transpoiter-2`Acknowiedgernent of Recelpt of Materials Date <br /> R <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> 20FaciItemlity Owner or Operator.Certification of receipt of hazardous materiels covered by this manifest except as noted In <br /> T 1 Date C4£ <br /> IF Printed/Typed Name <br /> Signature Month Day Year <br /> G a.l Ci e_1 <br /> f <br /> DHS 8022 A(11184) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> TEPA 8700.22) To: P.O. Box 3000, Sacramento CA 95812 04e9641 <br />