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• • Department of Health Services <br /> State of California—Health and Welfare Agency Toxic Substances Control Division <br /> Sacramento,California <br /> � Wease print or type. (Form tlesigned for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. ani est 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST - Do" of lawnot required by Federal <br /> 3. Generator's Name nd Mailing Address A.State Manifest Document Number <br /> D� 84692993 <br /> B.State :Generator's ID <br /> ,I enerator's Phone( ) aci <br />.. 5. Transporter 1 Company Name 6. US EPA ID Number C.Sletst Transporter's._3DM "` d <br /> r D.Transporter's Phone. <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E.Stete Transporters, <br /> . . F;TransporteesPhone <br /> 9 Designated Facility Name and Site A dress 10. US EPA ID Number G.Stale Facility'&1D - <br /> ;moo �+s;� pig ,0 -2 ,-O <br /> H.Facility's Phone _ <br /> �X 3 (0 6�a V%"`-901 S' r <br /> lz.uontainers 13. 14. ;__I•.. <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class,and ID Number) Total Unit Waste No. <br /> No. Type Quantity tlVo <br /> G / <br /> N a <br /> E <br /> R y�•� <br /> C4. A <br /> T b <br /> a <br /> 0 <br /> R <br /> C. <br /> d. <br /> J am, OditlpodDescilPtibns or•Masldalta UDledJ�DoyB_a�' ,�„y.,� " ,. •:_�.tian�uln codaar«wa8tae s r <br /> CAJ <br /> .? V J ��._q/ � �� 2S'W' of•S;� L�, :+'� YY� �"A;T .fes � � F. Sxr� <br /> Qi .r.7(J /r i �94r r l�Rt '3•.gxn' +<`a' `-`a _ :ur i <br /> �� •^d_dv. ° �" <br /> Ai h <br /> "qW 15. Special Handling Instructions and Additional Information <br /> 00 <br /> 10 <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 acc4ording to applicable inter tonal and ational ov n ent I regulations. Date <br /> Iv—t -7— c_ L-- . <br /> Printed/Typed Name- Signal Month Day Year <br /> if 5 D, yyrC� � 6. •661 <br /> T 17.Transporter 1 Acknowledgement o Receipt of Materials Date <br /> RMonth Day Year <br /> A —Printed/Typed Name Signature <br /> N Q' <br /> .. ... ... .. .. .__ Dale .. . - <br /> o 13.Transpor r'2 'Ackn wledgement of Receipt 0 Material's <br /> Or Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> i 20.Facllity Owner or Operator.Certification of receipt of hazardous materials covered by this manifest except as noted In <br /> I Item 9. Date <br /> T <br /> IF P IntedlTypod Name Signature Month Day Year <br /> r L M01iiC <br /> eo22 A(11/84) White: TSDF SENDS THIS COPY TO DOHS WiH61N30 DAYS 6489641 <br /> DHS DHS 8 2 A(1 To: P.O. Box 3000, Sacramento CA 95812 <br />