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• • Department of Health Services <br /> State of Calitornia—Health and Welfare Agency Toxic Substances Control Division <br /> Sacramento,California <br /> P'.ease print or type. (Form designed for use on elite(12 pitch)typewriter.) <br /> 1. Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS Docu is not required by Federal <br /> WASTE MANIFEST of law. <br /> 3. Genera is Name and Mailing Address A.State Manifest Document Number <br /> LAY /S% i�sicfl✓ 84692994 <br /> B.Stete Generator's:ID . <br /> 4. enerator's hone ) a— �l' - <br /> 5. Transporter 1 ComName 6. US EPA ID Number C.State Transporter'8-;1D= O +� <br /> 3CO (/O D:7rensporter'a F.hone <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E.State Transports a ID <br /> . . F.Transporter's Phone <br /> 9. esignated Facility Name and Site Addre s 10. US EPA ID Number G.State Facility's ID - <br /> leo�� 4(l f)� Sz' <br /> 36 k H.Facllit 'a Ph ne <br /> i 12.Containers 13. 14. <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity y Unit <br /> t vo Waste No. <br /> G <br /> S L145(� SO4l�S�(lO5 � � <br /> E - <br /> P <br /> T <br /> b. <br /> c <br /> P <br /> C. <br /> x_ <br /> d. , <br /> dj�] wlPtlpna 'Idat9rlale Uajted Aybove =;1,, , �; K,Handlinp Codas�or•Waeteittlafed X"J <br /> � <br /> JP <br /> CID <br /> 'W 15.Special Handling Instructions and Additional Information <br /> 04 Gid/ <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 /> or <br /> for transport by highway accngg to applicable fnternat'onal an� national ggovernmental regulations. Date <br /> PrintedlTyped Na a Signatu CC � Month Day Year <br /> �� <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials Date <br /> wPrintedlTyped Name Signature <br /> N <br /> Month Day Year <br /> E le- Date <br /> . _.. .. . <br /> I '18 .Transporter 2 Acknowle.gement of Receipt o materials - <br /> RMonth Day Year <br /> T Printed/Typed Name Signature <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 20.Facility Owner or Operator:Certification of receipt of hazardous materials covered by this �sfex"c s noted In <br /> I Item y9. Dale <br /> Y;. T Month Day year <br /> y Printed/Typed Name Signature �O/ <br /> n a.�+�✓ .�.-�- G <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS 8409641 <br /> DHS 8022 A(11184) To: P.O. Box 3000, Sacramento CA 95812 <br /> EPA 6700-22 <br />