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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 ID No Manifest 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST 7.4,_) ( .3�/ .� `S Documen o of iawnot required by Federal <br /> �.. <br /> Genera�°r's Name Ind Mai�lm Addles 1 A.State Manifest Document Number <br /> f Cil i,E":4,� "d�,a1 -,nLJ <br /> 4 icY Cit? �,G'Z r� �qL G/�'t '-S' S� _;�- B.State Generator's'ID <br /> 4. Generator's Phone( `�-� ) c� a -,"� <br /> 5. Transporter 1 Company_Name 6. US EPA ID Number C.8tate Transportsr'si1D <br /> ( —/ / �,r{-� ) r D.Tranapo[tel"s Phons ,d <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E.State-Traneponer's 10,:, a <br /> . . . . . . . . . F.Transporter's phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G.State Facility's ID <br /> / �(� �n,� ?��-L• H. ac 's lone = <br /> 12.Contamers 13. 14 + <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total Unit Waste NO. <br /> No. Type Quantity t/vp <br /> c l / � e <br /> N a *i4-� DA/S U14.> iG -/��: ,UOS rill / <br /> R <br /> A b. <br /> T <br /> 0 <br /> P <br /> C. <br /> d. <br /> _. .yD�e}yseApti_olls Ygr tal "tl. as F ' lJ sSed AboYec1 -Additional eKanling Wea•Lr" :. <br /> • V i Gib '� �rr :Jam' a�'tIIn r "a' 3. flYi -'X .{./ � [.S <br /> Y t S S S <br /> a , s <br /> 15. Special Handling Instructions and Additional Information <br /> � 00 11-ccs-P�,�� <br /> S /E.,57z- s <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 accordin o applicable international and natioAaI Duerr nt r gulagions. <br /> C,� �`�� Date <br /> Printed/Typed Name Signature ' Month Day Year <br /> C' rC,�1/� c, 1' , <br /> 7 17. Transporter 1 Acknowledgement of Re ipt of Materials Date <br /> Printed/Typed Name Signatuffir7 v Month Dey Y <br /> If <br /> bMir V5" <br /> .D- 18.Trans' rter"'2 Acknowledgement of Receipt of Materials I Date <br /> i <br /> Printed/Typed Name Signature Month Day Year <br /> E <br /> a <br /> 19. Discrepancy Indication Space e G <br /> na 6 <br /> F <br /> C <br /> 20 Facill y9Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted In <br /> I 1 Date <br /> v Printed/Typed Name Signatu Month Day Year <br /> rW 1� $- <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> DHS A022 A(11184) To: P.O. Box 3000, Sacramento CA 95812 6489641 <br /> (EPA 8700-22) <br />