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:,taco of California--Health and Wolfare Agency Department of Health Seer <br /> Toxlc Substances Control Dlvi.i <br /> • <br /> Sacramento,rally:•:-, <br /> Please jfrir;or type (Form designed for use on L 0 2 pitch)IypeHriter.) <br /> �I UNIFORM HAZARDOUS venerator s o. Manifest age n ormatlon in the shaded area,; <br /> Document No. is not required b Federe' <br /> WASTE MANIFEST C _/ (7�)�) i ',�.0 <:' -� of law. 4 y <br /> Generator's Name and ailing Address T. t a t­aNrt' �� <br /> f t u e t umber <br /> U S. IJi�vG_(=r�t�oilc:c rn�r.IT � <br /> y i �'. �� ��c tate enerator• ___. <br /> ►tor"s hone �t5t52t Glv> 4 U -4QGS5. XOG�DI�gq�3 <br /> 4. 4.neCrator s Phone ( I <br /> ransporser ompan-y- ame 6. US EPAID Number C.Stato ransporter s I <br /> j /�mt� l Eti I ►?�1�1+1'lr•N I /�L �.A n. � 8 35 3r�4 nanaportair na <br /> 7-Transporter 2 Company Name U. US EPA ID Number teteranspw er s <br /> 15 <br /> . . . . . . . . . ransptxter s no9. _ <br /> DesignatedFacility Name an Site Address Us EPA ID Number G.State Facility's <br /> ID <br /> �✓11C�.iC,/.-1►J C/�1V I lLC1r�.1111t=►vTXll- CADO(o�7��53(0� <br /> j 11855 VJ h t TG QC)C k ??,Jact r • one <br /> NCNO CG21i V q_j Cxl GS070 CA1).o(o­j .g.)-5.3,(,, VOUql(n)qe)5_(o(olu�o <br /> 12.Containers 13. <br /> i11.US DOT Description/including Proper Shipping Name, Hazard Class, and/D Number TotaLUnit <br /> a l I <br /> ---- -------- --- ---...- - -- --- -- --- No. Type <br /> arts No. <br /> E B. FIr7M�1� _ LAC, <br /> n <br /> ur�J IO(qQ -- ---- 2.5 Dn1 100 <br /> A <br /> b. _ F-I/attilrYlAtj= UQUIn — <br /> 1=TM <br /> p <br /> -- -- - --- - Ub 4DG SCSI I <br /> C. <br /> t=�i��►�rllll� - <br /> +-Ir'1mm���-ice <br /> d. HETI-INL ALC a HLL4 76 <br /> rIllrl1m,�r?X� j„!c>7 )rte la i�r►'1 3�j (� � � <br /> NI� SU t <br /> J—Addtt�onal Ueesripii ionar ateriali Uoted jCbovs <br /> K.Handling Codes for Wastes rst a <br /> A. ACLTW Q& 100 010 <br /> 8. F_YNLj(, aT14 C42 <br /> CJ 1'?'lE 114LJLAmIQF- 1C,0 /C) <br /> -- -sP 'Lia 1W/ �Te I <br /> 1. r nstruc/tro/ns/-a tionel- #*Mwn <br /> �_]. <br /> liI`JI4., A�>�21(�t� <br /> L TI '�`L`ZRYI�T TION:I horoby declare that the contents o this consignment ere fullyano accurately described � <br /> above by proper shipping name and are classified,packed,marked•and labeled,and we in all respects in r <br /> transportProper condition for <br /> by h.i�hway according to applicable Interhational and national governmental regulations. <br /> -------- --- <br /> Pr - -- -- -- ---- --- DLi a y <br /> Slynrture \ Month Day Yeer S <br /> s ..-+ <br /> � �'" w r6 lie V Err'14 <br /> t 17.Trenspo for 1 Acknowledgorr u 1f itelt►f bMate►ials } <br /> 121 <br /> R Date <br /> • / Printad/Typed Nemo ------------------- Slgheture - <br /> N � MontA D <br /> a K&j Y Y er <br /> C <br /> 18.Transporter 2 AcknowledCr�ment or obT olp f Materials �lJ <br /> R — Date <br /> T Printed/7ypod Name - --- Signature -- -- <br /> E Month Day Year <br /> R Is <br /> 19.Ditxrepan;.y Indication„pcCe <br /> k <br /> C <br /> I <br /> T <br /> 20. Facilityy Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T Item 19. <br /> —�rint�ff -ed Name - - Dete <br /> L-VI M -- - i�natur :---- <br /> I• /` "on <br /> D y Yeer <br /> r / it— � . <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> S 8022 A (7/84) To. A.O. 43-n <br /> 11n a2oo-zz) , Sacramento, CA 95812 <br /> N NMI <br /> r br '>KZ'flCAtfT <br />