Laserfiche WebLink
r Stale of CAllfornia—Health and Welfare Agency. • . Department of Health Services <br /> Toxic Substances Control Division <br /> ' Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS enYer�ators 1 o. anlest age Information in the shaded areas <br /> C1�.U.0.9 �3 D Is not required by Federal <br /> WASTE MANIFEST of law. <br /> gators Name nd M ifing Address Adt4e.hUnifeil Qofpment Number <br /> Eox*aA Vl�%F:L. b 11 4 u <br /> Z1ctr 79.Cy G� S�S)T,IP% Rb. <br /> 83(0- 30 s l B.Ca%%C0ga`t_a ,S <br /> 4. Generators Phone 1 �� 1 w '�` (,4 <br /> rransp�orr,0�er 1 C�to�mGp�atn'y Natm��e�/1� T��rs� �-��r SS EPA ID Number�l :State Transporter's ID a 'r. <br /> C` E%\Ki�yl \ \/Af3`G tA0AA JACNT M C_R.1)00.3. .a� / 1 .Transporter-s Phone _q3S ZC" <br /> 7. ransporter Company Name U. US EPA ID Number E. tate Transporter's ID <br /> L . . . . . . . . . . . F.Transporter's Phone <br /> i a Fac Ii ame ndt it A s 10. US EPA ID Number .State Facility's ID <br /> Irpeltw re h_� �� C T (o <br /> KH )P91pu N� s r m,% ,4-/ <br /> 3s ! Yew °u� a3o13q C� r.pp.o.� 4G. �.1 -7 d04"-6 Phone <br /> g - 9'71 1 <br /> 11.US DOT Descri tion(Including Proper Shipping Name,Hazard Class, and ID Number, 12.Containers of 14. <br /> P I 9 P PP 9 Total Unit Waste No. <br /> o •• G y� NO. T e Quantity <br /> H I�I1Zp12�0US wwSjE SU SVS �l�S <br /> 13pt qI� ' ©bl DT U �1 <br /> A b <br /> T <br /> O <br /> R <br /> C. <br /> d. <br /> J. Addition'ILDescriptions <br /> yions 19F Materials Listed Above dling Codec for Wastes Listed bove <br /> pedal andling nstructions and �yltione[ I or(�^^ation <br /> 6O&GIES $ Io•lES �EQ�\1:E V <br /> CN, 01 s <br /> 16.GENEFIATOR'S CERTIFICATION:I hereby declare that the contents of this consignmene.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 /> Date <br /> Pyped�Neme,— t2 Sig Mgprh DeY Y4�er <br /> T 17.Transporter 1 AcknowledgementtgelrmJ1ent of Receipt of Materials (� Date <br /> R <br /> A Prin /Typed Name SignatuM ( Mggrh Day Year <br /> 0 18.Transporter 2 Acknowledgement or Receipt of MaterialsDate <br /> R <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> L <br /> 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> yhem 19. <br /> Date <br /> rioted yped Name ignature Month Day Year <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 /> TEPA 8700.22) <br />