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State of California—Health and Welfare Agency Department of Health Servlcp <br /> Toxic Substances Control Dlvl;lon <br /> Sacramento,California <br /> Plooso print or type. (Form designed for use on elite(12rpitch)typewriter.) <br /> UNIFORM HAZARDOUS 1 Generator's US E A ID No. Manifest 2.Page I Informationinthe shaded areas <br /> Document No. of is not required by Federal <br /> WASTE MANIFEST �' P 9 9 �'�'d • • • law. <br /> ' �ncratnl;: no a I Ing rjsg A t n if t•-. oc ment Nu(nberr�• <br /> J yy } to e r 450 b ; <br /> >• r c u r <br /> g B.StateGenerator's,ID Ott <br /> 4. Generator's Phdne ( O ) - / <br /> nsporwro <br /> ,I-. G C �t'n!pang� ame U EPAD Number :State,: ransponer's <br /> T-- T = C. D.Transporte(Is Phone,, 9 0 ; <br /> ransporter 7. Company"Name 8. US EPA ID Number E. tate Transpono('S ~ <br /> . . . . . . ransporter s P.hpne�;,,9. <br /> Designatedaetlity Name and Site Address 10 <br /> US EPA ID N bet G. tate ,Facillty a IQ <br /> 35"aSI o%I $fit ` ' <br /> I; .Facllit 'S'Phone,. ttls ; <br /> 12.Containers 13. 14 a; <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class, and ID Number) Total Unit <br /> G No. Tyne Quantityd iWaBteNq <br /> E a• <br /> H <br /> E A /7.to. ZO Uq ZO/67 0 0 7 -r <br /> b. <br /> T W> figi; tjY<r <br /> j <br /> C. <br /> d. <br /> J .;AdditIgn4 rte' BiI�aeS18 any Ve! r Y r{ y��� m` !�Hendh9 <br /> n Code � �B <br /> f r aS <br /> r L ''k► ' � a. .I. y+ ISiY �t5} <br /> Q„'1 �1.a33.+�� l ''., 1 •� ,r� t ��� �� � ;'' ���'+, ' :1• •71 1_. ld.'�� ¢ `!r <br /> 0 <br /> t y'1+fy <br /> ti i t {' •S � !r 'Y i � �y .{ �.{�,J�r9i , L 1, .: .'. <br /> 15. <br /> �;-.!.1.5^T I ,i+'.. _.,, ,''�!}#h'u-�'�3' t'}..'�Z+�- 8.y". •f�i', t'ti'^!,r v :7 �,�r 'r'� j ''� ,;� �,(�1 A r,�],,try' -f ,. <br /> Special an hng Instructions and Additio`n_777o�rmatjon <br /> 16. ,F A R F ! hereby dec!arethstthe contents o this, oneignmantarc f:;fyand accuratolydesc,ibed <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 to applicable international and national governmental regulations. <br /> Date <br /> Print d/Typed Name Signature Month Day Year <br /> 'I— /7 /'2 /'1 S <br /> T 17.Transporter 1 Acknowledgement of Re t of Materials Date <br /> R <br /> A Printed/Typed Name Signa Month Day Year <br /> " c3' s <br /> S <br /> P "- <br /> 0 18.TransporteV2 Acknow edgement or Receipt of Materials' "- Date <br /> R <br /> T E Printed/Typed Name Signature ® Month Day Year <br /> R <br /> 19.Discrepancy Indication.Space l_ <br /> F DEC 191985 <br /> A <br /> c <br /> I <br /> L <br /> I 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by t Vll 1/J I?AEj jf"d in <br /> ,T Item 19. Date <br /> Printed/Typed 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 84 8915>411 <br /> (EPA 8700-22) <br />