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Slab d Csllfofn alth and Welfare Agency • • Department of Health Services <br /> Toxic Substances Coatrp Dlvlslon <br /> Sacramento,California <br /> PINK pnnt p type. (Fpm designed for use on silts 112-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 11. Generator's US EPA ID No. Manifest 2. Pape 1 Information n thea areas <br /> WASTE MANIFEST ocument No. of is not required by Federal <br /> 3. Generators Name and Melling Address <br /> taw. <br /> ILDORADO MEHI= 00a r INOa <br /> 4. a,8oD "PhaoRlRzCR NAY, eMCgTOxa CA 955 <br /> 5. Transporter 1 Company Name 8. US EPA ID Number <br /> It'7. Transporter 2 Company ami 8. US EPA ID Number <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number <br /> U V CI GRASSY MOUNTAIN FACILITY <br /> 3 MILE 8 E Adie 7 MILES NORTH OF U 70991301748 <br /> KNOLLS EXIT OFF I.80 OLIVE U . <br /> 11.US DOT Description(Including Proper Shipping Hama,Hazard Class,and ID Number) 12'Containers TotalUM <br /> o No. Type Ouantty WtNo <br /> a' <br /> HAZARDOUS NASSiAlIQJID naos a s. ORM..E <br /> NA9189 Ol T? Agon <br /> T b. <br /> 0 <br /> a <br /> C. <br /> d. <br /> .;� KHandl� }etsi <br /> 100 <br /> 15.Special Handling Instructions and Additional Information <br /> WAR PROV%CQIV& CLOTHING, GLOVES, MOTS$ FACE SHIELD; <br /> 16.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consionment 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 according to applicable international and national governmental regulations. <br /> Date <br /> PrintedlTyped Name L !of <br /> Y MOGOMAN Sign Month Day Year <br /> L DOR DD <br /> T <br /> 17.Transporter 1 AcknowledgementReceipt of Material ea rintedlTyped Name Si natu■ 9 Monrh Day Yeerio f ransport r 2 ckno ledgem nt ecelpt o Materials Date <br /> i Printed/Typed Name Signature <br /> a Month DayYear <br /> 19. Discrepancy Indication Space <br /> r <br /> 4 ' <br /> C <br /> I 20 Itemity Owner or Operator.Certification of receipt of hazardous materials covered by this manifest except as noted In <br /> v PrintlledlTyped Name Signature Month Daly Year <br /> Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> DHS 8022 A(11184) To: P.O. Box 400, Socromento, CA 95802 e.eae.1 <br /> (EPA 870022) <br />