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------ ----- i <br /> ' Department of Health Services <br /> tate of Callfornia—Health and Welfare Agency Toxic Substances Control DI Islon <br /> Sacramento,California <br /> lease print or type. IForm designed for use on elite(12-pitch)typewriter.I 8nl est2.Page I n ormalion in the ShaOed areas <br /> UNIFORM HAZARDOUS CkZ Qt�.sq.16333-'o-6+ 115 D �gr60114 of I iss not required by Federal <br /> WASTE MANIFESTV V(� t e n e mant Number <br /> Address <br /> o B am��ntl .Mag D9 S2 4 4"�'�� � <br /> , U W�1Q�tG� <br /> 1lBY tate eneretor's I <br /> T'"ACYCA - AS'a �3�" ads 1 335 <br /> 4. Generator's Phone ( 1 U EPA ID Number C.State iransporter's ID <br /> 5. ransporlser 1 C, ogt�SjE ar �N`ran b � ' D.Transporter's Phone <br /> CMT4091 i Fri CA.D. 3 q 0 <br /> Transporter7. Company Name 6. US EPA ID Number E. tate Transporters ID I <br /> F.Transptxter's Phone t t <br /> C� It 11, �e1c to Adaret 10. US EPA ID Number G. jri?e Ptacility <br /> '�eail�i s Phone <br /> � <br /> 35S I t_D KSI l� }: q3 3°I CPtT 06.0.6 4 bl . 7 20 <br /> 12-Containers 13. 14. 1 <br /> Total U d Waste No. <br /> 11.US DOT Description(Including Proper Shipping"I Hazard Class, andID'�Number No. T Ouanti <br /> w a <br /> E a. A' R1DOu S 6TE ��-p1 i OS 1 KJOS <br /> C>01 <br /> E <br /> A b. <br /> T <br /> d — <br /> R <br /> C. <br /> d. <br /> K.Handling Codes for Wastes Listed Above <br /> J—Add <br /> iti nal iptions Ix eteriels Ust Above <br /> 16.Specust Handling nstOr ns a� dditional In olm lti E,�, <br /> COPS- D - SppS�b 1-_Jo 1 S <br /> 1 above <br /> Aro Ra shippingpiname and are classified,packed,marked,and latbeled,anldxeinsllerespects in proper clondtonbf for <br /> a anspor p pe Date <br /> transport by highway according to applicable international end national pavernmental regulations. — M nrn D Y Year <br /> sgLA I <br /> pri `�yGame � r�✓at(� <br /> �Vw F Date <br /> T 17.Transporter 1 Acknowledgement of Rxeipt o1 Meteriale of yp DZ �r <br /> Name 6 <br /> Pri ted/Typed _! <br /> c Z Date <br /> 0 18.Transporter 2 Acknowledgement or Receipt of Materials Monrn Day Yeer <br /> Name Signature <br /> T Printed/Typed - <br /> E <br /> R <br /> 19.Discrepancy indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> L <br /> 1 20.Facility Owner or Operator: Certification of receipt o1 hazardous materials covered by this manifest except as noted in <br /> Date <br /> T Item 19. Monrn Day Year <br /> gnature <br /> Printed YPed Name <br /> Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />