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0 <br /> State of California—Health and Welfare Agency Department of Hearth 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 11. Generator's US EPA ID No. Manifest 2. Page 1 Information In the shaded areas <br /> WASTE MANIFEST 74z) . R. 5- Docum t o of iawnot required by Federal <br /> 3 Gene tor' Name and M ling Addre¢s A.State Manife t Document Number <br /> C'a�,� Jv— off s qe,_� �7�/J 8469H91 <br /> Xiob�z5%O �f �S S B.State Generator's ID <br /> 4. Generator's Phone( ) 1 <br /> 5 Transporter 1 Cyr party Name 6. US EPA ID Number C.State Trensporter's.ID' <br /> D.Transporter's Phon <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E.State T-ransporter's ID ':� <br /> . F.Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G.State Facility's ID :- <br /> �Fi IE'UppG��ut4.� GLIAS� /AX- q 0 �7 � <br /> (,7 80X 334i� H.Faclll y's Phone <br /> -CA -0alp - s Sas �3s � <br /> 12.Containers 13. 14. <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total Unit <br /> 0 <br /> No. Type Quantity Ifvol waste No. <br /> E a.// <br /> b' <br /> T <br /> O <br /> R <br /> C. <br /> d. <br /> J. _Additional Descriptlpna tor_Materlals Usted Above - KHandling Codes for Wastes lis, hove <br /> Y. a. <br /> :_1.X/^vl�dsGl/.UJ4-'r <br /> C\J <br /> co <br /> r.. <br /> 15. Special Handling Instructions and Additional Information <br /> 00 <br /> Girl <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 ac co i tc erPp> able Intern Tonal grld�tation�(_gl �ental regulations. i] <br /> 7 i0 Date 1 <br /> Printed/Typed Name Sign p l Month Day Year <br /> `-tam• ,(/. Y� i.h .'5�10..e <br /> T 17.Transporter 1 Acknowledgernfint of Receipt of Materials Date <br /> N <br /> P Inted/Typed Na Signat e s Month Day Year <br /> 0 <br /> ( U G <br /> o .'Transporter 7 Acknowledgement dt Aedelpt of Materials Date <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> 20.Facilityy Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> I Item 19. Dale <br /> f T <br /> It Print /Typed NameSlpnatur Month Day Year <br /> 0 ob <br /> DHS 8022A(11184) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS 9489641 <br /> (EPA 8700-22) To: P.O. Box 3000, Sacramento CA 95812 <br />