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to of Callfornla—Health and Welfare Agency • • Department of Health Services <br /> y t TOXIC Substances Control Division <br /> Sacramento,California <br /> ease print of type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS "gra r o. arrest age normationinthe shaded areas <br /> WASTE MANIFEaSi1Ti .05. S� of is not required by Federal <br /> law. <br /> erato%lge V4CMai(i;gCAddress t„St(ateAhk%fe�fkofyment Number <br /> 76. EST ,}wTI�L9'"537 0� _ a f� (� r' <br /> ��LK►c,/`�i9- v( g3(o d► S I eCA06,`aco` 335to <br /> 4. Generator's Phone ( `r"l , ) <br /> G- ransponer 1 Co pang fame OW U E tate Transporters <br /> Phone <br /> ID _ <br /> HCPjI Cl(,1L �K1S1G IVt�1>Jp6 T C� D.O.t�3`�.f�,`�`1. 15 D.Transporter's Phone <br /> Transporter Company Name 8. US EPA ID Number E.State Transporter's ID <br /> . . . . . . . . . . F. ransporter's—Phone <br /> — <br /> 10.f)�,gf{ltaq�FaGthq�� e„e(td e. re V. 10. US EPA ID Number G. �ejFOaci i ID <br /> bj�')l <br /> 1IIE+ IE:MwU 1NXk1,5 FALL(,�� t'� 1 <br /> 3 a an6Kyl;►j� c;�,r g3a39 q. T .�o.� b4.(D. 1 .177ID9�a3Ve, 4 11 <br /> �, <br /> 12.Containers 13. 14. <br /> 11.US DOT Description/Including Proper Shipping Name,Hazard Class, and ID Number Total Unit Waste No. <br /> h C '/� �i No. Type Quantity <br /> 501,05 I\Aus <br /> o� -E Vp% qua _ 00 DT <br /> A b <br /> T <br /> 0 <br /> R <br /> C. <br /> d <br /> J. Addi:�na ipti aterials Listed - K.HarWling Codes for Wastes List <br /> p. SOIL '7 �. <br /> qK- <br /> 15.Special Handling Instructions and dditional In ormation�� / Yt <br /> ov <br /> COA - 0 - BDD5-7 - o1G <br /> 16.GENERATOR" ERTIFICATION: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 for <br /> transport by highway according 10 applicable international and national governmental regulations. <br /> q I�/'� �n Date <br /> Pr�/T�ypPdt am G..Jl3.'�1'� Slg rh Y v.1 <br /> T 17.Transporter <br /> 1 Acknowledgement of Receipt of Materiels Date <br /> N Prpttpolr ale (GAJ SI M D Y <br /> s C <br /> P Date <br /> 0 18.Transporter 2 Acknowledgement or Receipt of Materials <br /> R Month Da Year <br /> T Printed/Typed Name Signature Y <br /> E <br /> R <br /> 19.Discrepancy Indirstion Space <br /> F <br /> A <br /> C <br /> 1 <br /> 1 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T <br /> r Item 9. Date <br /> Printed/Typed Name ignature Month Oay Yeer <br /> Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> DHS 8022 A(7/84) To: P.O. Box 400, Sacramento, CA 95802 <br /> rr.1111641 <br /> (EPA 6700-22) <br />