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j <br /> I I . <br /> State clC411furela--Hea8h end Wellen Agency papeamsnl of Health Services <br /> I Form Approved OM No.ROW—CM fExpAae 9.90-e 1) Toxic Substances Control Divirlon <br /> i `PWest print or type. (Form designed for dat oa*ata(12-pitch typowrfww). Sacramento,Celtfornl■ <br /> UN1FORV HAZARD045 f.6amrator'e US EP po. oMa�Hs1! R.Papa 1 Inlormellon In the shaded erase <br /> WASTE MANIFEST l m le not roquhed by Federal low, <br /> «� 9.Oea@raloes Nemo.sd Maiiing Addreesss (7at i 7tS r„ <br /> IAMIom+ F <br /> IMS <br /> 4,Generator'%I"onOl J r I �` ',r •� �, .i ;1=r r1�_ <br /> 6.Tranpportpr 1 Company Name b. US EPAID Number p '+ <br /> H <br /> 7.T anaportsr 2 Company isms ' 8. US EPA b Numbar <br /> r:i h1 ., cf.91 i ,, f <br /> 2. pa;fgrlatod Fsrilty Noma and 11111 Addrs.e 10. U9 EPA ID Number' r <br /> t v <br /> Ci A n 91 A A 6 7 <br /> r "1.2.ComcNgre <br /> F 1 t. US DOT Description(including Proper Shipping Name,Harard Claes,and Ip Number) Quanflly Uni! 'tYp4k7c <br /> No. Type WI/Voll --t <br /> a. <br /> CAUFORNIA KNATED W= MLY RM RCPA 001 D700020 Y <br /> ! S. <br /> Rb. Btela <br /> T EPAITkhof <br /> .k fl c. <br /> EP�!! K �S <br /> ., d. 5TF r i ^-a <br /> t(1 `I <br /> [: � �: �£'��ij'�T':'!l'!'Fftt�..R�• f"^'"'-� Y��AC `., tr,*.. <br /> ' �� ' ,r � i�i5�� �° L�L'S §���'sa�_; _ 4}`'•�,r X•t �r. .r' ��lq,: _ ', <br /> k' <br /> .•„t, q- +iu y ti(rf � d r H'-f#}.- r.r o �y',.�`�'�YrK � a °moi , .a�s�'`,'R' x '`�� � � <br /> : 1Soti•n."; '��, !.rES...tx�' .Yk:e1.'s�-,y`` S �'YJ3,,61. % �iF.�`e"sr �k ' rL? `i r r •.a .4 '- <br /> ' 1i.'apeel�l hangll071netruelWna and Addklonal lnlormatlprr ...... •..,_,,..._..........-_ ..........- - ..:... •. .. <br /> �a JE�MI <br /> G$UI:MTOFI'S CEFITIFICATION. I hereby dacitre that the contents of thic consignment aro fully and sccuralely deacribed fbgye by proper&hipping name <br /> and are classified,pecked.marked,and labeled,sed are Id all respects tri proper condition IF lrs>lrpoq tty plghwsy acpardlnq to applicable Intematlonal and <br /> national tfaY'smratnf fequlstions." <br /> H I fum a l.rgs quanlay generator.I cedity that f hate a program In place to reduce the Vofump and toxicity o1 waste 9arltralad to the degree l have determined <br /> Io bo oconomiaafry practicabla and that I pave s!Wclad the predicable method of trealmeol.Owego.or Qispoo4l 4urranlly Aveyable to ma which minimize.the <br /> phi and future threat to human hasltb end the environment:CM.[I,-em a small qusnttt enerator,I hey mail i flood hllh effort to minlmlre my waste <br /> Qaetration and select the bast washmonsgoment method that IS svaflobls to me and Iha ern afford. <br /> 1 PrklId/Typed Name - Sig( Month Day Year <br /> "M Tr"sporler 1 Ackncwlydpamenl of ReoW of Malodab. <br /> S y�i A Ponledrryped hares Sgnerurf MonM pay Year <br /> 10:Transporfar I Acknowledgement of Receipt of Materials - - <br /> i PtfetedrTYpad Name rSl &lure Month Day Year <br /> __ _ ... ..,..� _ w•:+•;r"... ... � � .._.,:, r, jam,. _. ,.�.`s •_.., ._. -- _ ,_ � ;, y ! _..... <br /> J <br /> 10.Discrepancy Mdlcatlon Space - <br /> G <br /> t <br /> L <br /> -I 20.Fadlity Owner or Operator Cortfllcatlos of racelpt of hazardous matariele.covered by We meniteal txcep(u noted M Sem 1g.' '- <br /> .i T Prl^ladfTYpad Name 3lpoalura . Month Day Year <br /> i? Y <br /> DH;8022 A(t vagi) Do Not Write Below This Line <br /> - fAaY•f1't10)Previous polllona are obadala. <br /> :.., YELLOW: GENERATOR RETAINS <br />