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of California—Health and Welfare Agency • Department of Health Services <br /> Toxic Substances Control Division <br /> I Sacramento,California <br /> se print or tYDe. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS n rat'p�1 0. p antest 2.Pago I I Information in the shaded areas <br /> " 5 b q, ��tene•Ne� is-not required by Fedldral <br /> WASTE MANIFEST 3 of law. <br /> RM�pQ.t7deiling Address f�Si�le��p%fej{ goyument Number <br /> 3 A Pl`cv (4E 11.�841 <br /> ta.W7G.oqB.SttaI Geere�rls IID Phone (ompany me [is EPAJ�f�uy�b� tate Transportat's ID_11(- AIAM (�WT AO(J � �}b (. D.Transporter's PhoneCompany Name B. US EPA ID Number E.State Transporter's ID <br /> . . . . . . F, ransporrer's Phone <br /> �LF cit" J1�Awe„gfAc" , sAT v 70. US EPA ID Number . tate Fact <br /> li s ID <br /> pIJ Hi7,�5 �AGt 2+ t'r""UU �Y"� C1tt�(ol� <br /> c� �iosKyg3� CF17v0.O.b�.b. 1.11 F � = - q-7 <br /> 12.Containers 73. 14. <br /> 11.US DOT Description/Including Proper Shipping Name,Hazard Class, and ID Number Total Unit 1. <br /> 11�y�� No. T Ouanti Waste No. <br /> a. �CZW Y2�D�l�S N15TE �:L� / � �Q <br /> a1il <br /> Uq o� bT 000 I y <br /> b. <br /> C. <br /> d <br /> J. it I. I one or ermis Listed Above K.Handling Codes for Wastes Listed Above <br /> 16.Special Handling Instrunions and Additional Information <br /> CCA - - gocC)S-7 <br /> ENE AT R'S ERTI FICATIO N: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 we in all respects in proper condition for <br /> transport by highway according to applicable international and national governmental regulations. <br /> Date <br /> Pri o m�!�w /^ Signatu Mirh Ljay Ye� <br /> 17.Transporter 1 Acknowledgement of Receipt of Materials 4' Date l� <br /> Printed/Tvgaa No a Si re Mon7rh Day Year <br /> DiN ��r ��---� D U G Y 5 <br /> 18.Transporter 2 Acknowledgement or Receipt of Materials' Date <br /> Printed/Typed Name Signature Month Day Year <br /> 19. Discrepancy Indication Space <br /> 0.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> Item 19. Date <br /> rinsed yped Nome Signature Month Day Year <br /> Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> 18700-22) <br /> 22 A(7/84) To: P.O. Box 400, Sacramento, CA 95802 <br /> w evert <br />