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Stale of California—Health and Welfare A enc Department of Health Services <br /> g Y Toxic Substances Control Division <br /> Sacramento,California <br /> Pfease print or type. (Form designed for use on elite(12-pitch]typewriter.) <br /> UNIFORM HAZARDOUS 11.Generator's tf,S EPA ID No. / Manifest 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST G, 8/ DocumNo s not required by Federal <br /> of law. <br /> 3 Generator's Name and Mailing Address A.State Manifest Document Number <br /> 00 CaL-i(—' r� r�i r-+.ls po,e� 1—/e) / 84692992 <br /> 7,l Eu£t�q.�� �tl� WO0Z-Sio CA S.State Generator's 1D <br /> 4. Generator's Phone <br /> 5. Transporter 1 Cony Name 6. US EPA ID Number C.State TratispOrteYe. ( 5 <br /> Lair-aian /k G A f D.Tranapottefs Phone. <br /> 7. Transporter 2 Company Name 6, US EPA ID Number E.Statb,Trahepill'ter's-1D <br /> . . . . . F.Tri isportsr'a-Phone <br /> 9Designated Facility Name and Site Address 10. US EPA ID Number G.State Facility's ID <br /> � � L�c{u7i WA5/' lft/� O Sd- <br /> � x H. ac lily's P one <br /> 12.Containers 13. 14, I: <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class.and ID Number) No T e Total unit - Waste No. <br /> �//��fp ,1 !�, YP Quantity hVol <br /> N <br /> a!T K ZK�—/ L —/J�S AlOS ✓^'/z ^�s .> <br /> E <br /> A <br /> ss A <br /> T b. <br /> 0 <br /> e <br /> c. <br /> d. rsy st. <br /> J <br /> (T) ll Add ltBlnal r�Aftterisls tJatet 1>Dva "a` H$ntllinA 4 r- "- <br /> 'J (V�/ <br /> 11j <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 actor Ing to applicable Internationel and national g vernm ntal regulations. <br /> / E.L1 b� &44- Date <br /> Primed/Typed Name. Signs tu r Month Day Year <br /> 0 J7 <br /> .T nsporter 1 Ackno lodgement of Recelpt of Materials Date <br /> Pr ted/Typed N SI natof Month Day Y ar <br /> N <br /> S <br /> P '1 . rahaporterAlowledgement of Recelpt`of Me erials Date <br /> i PrintedlT ed Name Signatu Month Day Year <br /> E <br /> e <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> I 20 Item � <br /> iityOwner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted In <br /> r 1 Date <br /> If Print /Typ7 Name S!gn_!tu;C Month Day Year <br /> od <br /> White: TSDF SENDS THIS COPY TO DOHS (THIN 30 DAYS <br /> DHS 11022 A(111/84) To: P.O. Box 3000, Sacramento CA 95812 8469841 <br /> (EPA 870022) <br />