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Stole of Cofnornie- Heelln and lVeffare Agency r- Department of Health Services <br /> Form Approved OMR No. 2050-!0039(Expires 9-30.80, ] ( 1 Toric Subsiances Control Division <br /> Planse rine or type. Form desi ned for use on elite G 1 f w <br /> eriff,). v Sacramento.California <br /> UNIFORM HAZARDOUS 1. l'ererstor's US EPA ID No. Manifest Page 1 Information in the shaded areas <br /> Document No <br /> WASTE MANIFEST / b ( S q / °}. snot required by Federal few. G <br /> 3. Generator's Name and Mailing Address ..' A. State Manifest Do > <br /> P.O. BO U.S.A. INC. :- .,•' 874E01-1 <br /> I - P.O. BOX 5004 - R.6tete Genoretor eJD - I <br /> a. EX SAN ON, CA 94583-0804 ¢ <br /> 47 42- 631 ` <br /> N S Transporter l Company Name e. US EPA ID Number. P. State TransportefsaD:� <br /> a <br /> D. Trenaportar'e Phoney,_[ � <br /> 7. Trenaaorte 2 Com any a . "a .- 8S EPA ID Number E. State Trans orter•ID,- - r <br /> m P <br /> gi r. f .Transporter's Phone <br /> m <br /> 9 Designated Facility Name and Site Address 10. ,. US EPA ID Number Q!=&feta Facility's HI - <br /> R / <br /> _J '95 . . } N. `'�' t <br /> 2 JclCS oni'': r r <br /> Z So'. �R 131E Cl voa rt„Facility's en?me,`a tk <br /> r <br /> z <br /> - 12.Containers 13. Total 14. <br /> \\; '-p - ' <br /> US D0T OeacPRtion(Including Proper Stripping Name,Haza tl Class.and ID Number) Quantity Unit Waste No. , <br /> J .. - No. Type- wtivo <br />� 0 a:..V1/A e / ti js T S T2,4 G t'. -r-A yr&S - State <br /> Z .G r - z <br /> Y. :E' CA7 �y FP/Li�r rpt {F,c-'�A �v.a/ YM:Gt3�E + - _ PAfOthsr <br /> Nb i - - ? - /, ,. - . _ __ - e Stats . <br /> mo A <br /> m - .. - EPA/Other . <br /> o' <br /> T <br /> N <br /> C R C - - statee <br /> up <br /> m <br /> EPA/Other �.. <br /> Iw <br /> w d. - Stara _ <br /> Z <br /> Z <br /> 1 w <br /> O EPA/Other <br /> w <br /> Z J. Additional Descriptions for Materials UeJetl Above ._ K Handling Codes for Wastes Listed Above <br /> w <br /> c. d <br /> Q <br /> I15 Special Handling instructions and Additional Generated Site Address <br /> = <br /> _w G/r'✓_`.� � o-sG(s �. ev4mr✓ 74--r”' <br /> J 16. <br /> i. GENERATOR'S CERTIFICATION: I hereby,declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> name and are classified, packed. marked.and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> international and national government regulations. <br /> n If 1 am a large quantity gen9rator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have <br /> -'s determined to be economically,practicable and that 1 have selected the practicable method of treatment, storage,or disposal currently available to <br /> me which minimizes the present and future threat to human health and the environment: OR, it I am a small quantity generator, I have made a good <br /> r laith effort to minimize;my waste generation and select the best waste management method that Is available to me and that I can afford. J <br /> Z <br /> jPrinted/Typed!NameSignature _ Month Day Year <br /> 2 <br /> yRT 17. Transporter 1 A nowletlgement o6Recaipt oWaterials - <br /> 1 A Printed/Typed Name <br /> N Month Day Year <br /> l S / <br /> D P <br /> O 18. ransporter 2 Acknowledgement of Receipt of Materials <br /> n R Printed/T d Name <br /> T yPe signature - - Month Day Yeer <br /> E <br /> 19, Discrepancy Indication Space <br /> F <br /> C �. -.. <br /> V <br /> I <br /> {- : 20. Facility Owrwr or Opersfor Certification of receipt of hazardous materials covered by this manifest except as noted In Rem to. <br /> T Printed/Typed Name Signature <br /> y. Month Day Yeer <br /> DNA eon A(1/87) A Blue: GENERATOR$ENDS THIS COPY TO DOHS WITHIN 30 DAYS, ` INSTRUCTIONS ON THE BACK <br /> ii <br /> Rev.89-M) Previous echidna are obsolete. To: P.O. Box 400, Saf:rameni CA 95801 <br /> r . , <br />