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Stale of California—Health and Welfare Agency Department of Health ServicesToxic Substances Control Division <br /> Sacramento. California <br /> Please print or type. (Form designed for use on elite(12 pitch)typewriter.l <br /> UNIFORM HAZARDOUS ' Generator's US EPA ID No. Manifest 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST 7 /1 t . $�f� S'� _ .CIS Docume t N l <br /> o1 anot required by Federal <br /> law. <br /> 3. Generator's m <br /> s Name and Mailing Address A.State Manifest Document Nuber <br /> i <br /> ei C64.9 84692988 <br /> Estate Generator's ID <br /> 4. Generator's hone( ) i /` <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C.State Transporter's I Q'i^ <br /> i_ - 1 D.Transporter'a Phone <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E.State Transporter's ID <br /> . . . F.Transporter'sPhone <br /> 9 Designated Facility Name and Site�ddress 10. US EPA ID Number G.State Facility's ID <br /> p <br /> I -t L4G1 N{�cS i -ice C7 6 <br /> H.Facillty's Phone <br /> l 3" 8s > 9" 3 asS3.5 <br /> 12.Containers 13. 14, <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total Unit Waste No. <br /> G <br /> No. Type Quantity uvol <br /> E a,�/ u lG asp cJJ��s9- <br /> .� A <br /> In. <br /> T <br /> 0 <br /> R <br /> C. <br /> d. <br /> 00 a <br /> 010 J Additlonpl Descrip]]f'��e�4yyfar-MJ ysted�}144vp f 'r fl f y iC Hagdllnp Cadea fgr W$etee y Alzove. <br /> CVo, <br /> 14 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 acc r Ing to applicable International and national gqvernmental regulations. <br /> T / "iP C Date <br /> Printeedd/Typed�7Name ,, �I , Signatur j ' Month Day Year <br /> 0 17 <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R <br /> Prima ed Nam ure � Month Day Year <br /> N <br /> a 7 L% <br /> P - <br /> - 0 1 nsporter 2 Acknowledgement of RecdIpt"of"MateriAle-'" - Date <br /> R <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> M <br /> . <br /> 19- Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 20.Facllltyy Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted In <br /> T Item 19. Date <br /> T Ze <br /> d/Typ d Name Slgnatur Month Day Year <br /> D r O <br /> White: TSDF SENDS THIS COPY TO DOHS VITHIN 30 DAYS <br /> DHS 8022 A(11/84) To: P.O. Box 3000, Sacramento CA 95812 8489841 <br /> (EPA 8200-22) <br />