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Slate of California—Environmental Protection Agency
<br /> Form Approved OMB No.2050-0039(Expires 9.30-991 See Instructions on ba,.00f page 6.. Department of Toxic Substances C
<br /> ` Please printer type. form designed for use on elite f 12�)typtwriler. Sacramento,California
<br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas
<br /> UNIFORM HAZARDOUS
<br /> is not required by Federal law.
<br /> WASTE MANIFEST Fa T: f CI ; 1 1 5 7 of 1
<br /> 3, Generators Name and Mailing Address n rm I t
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<br /> W. KE:•rTLEMAN LINE, Lt�D I , CA '��i'2 4:::
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<br /> sn y4. Generator's Phone 12 0 1 t''•' ## #, e! 1 a &
<br /> N 5. Transporw 1 Company Name 6. US EPA ID Number
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<br /> 7. Transporter 2 Company Name 1 ; e
<br /> Po p Y 8. US EPA ID Number s
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<br /> 9. Desipaled Facility Name and Silt Address 10. US EPA ID NumberID
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<br /> 12. Containers 13. Total flCudl r r°'
<br /> 11. US OCT Description 1;, :uding-Proper Shipping Nome,Hazard Class,and ID Number( No. T e Quantity Wt/Vol Nurpbec
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<br /> O 15. Special Handling Instructions and Additional Information
<br /> ►= f;f•f-POPk I HTE FrF:u TEC-T I v'k:
<br /> 11EMEF:GEN1=Y coi\rrAt-:T: i ��'i:► i�Fl-'314;i'r
<br /> _ 'Et E. M. G. 171
<br /> Q16, GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper ship P Ing name and are classified,packed,
<br /> U marked,and labeled,and we in all respects in proper condition for transport by highway according to applicable international and national ga ernment regulations.
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<br /> If 1 am a large quantity generator,1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economicallyy
<br /> Npracticable and that I have selected the practicable method of treatment,storage,or disposal currently available so me which minimizes the present and future threat to human heahh
<br /> Od and the environment, at I if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is
<br /> available to me and that I can afford.
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<br /> y Printed/Type a ff Signature Month Day Year
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<br /> (U LU 17. Trans otter I Acknow a ement o�Rec I of Moieriols
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<br /> A Printed/Typed Name Signature Month Da Year
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<br /> U_ 6 18. Transporter 2 Acknowledgement of Receipt of Materials
<br /> 0 T Primed/Typed Name Signature Month Day Year
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<br /> U F 19. Discrepancy Indication Space
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<br /> 1 20. Facility Owner or O e olor Certification of races t of hazardous materials covered by this manifest except as noted in Item 19,
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<br /> Si nature
<br /> r / g / r Month Day Year
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<br /> DO NOT WRITE BELOW THIS LINE.
<br /> pTSC 0022A 11/97)
<br /> EPA 5700-22 Green: TRANSPORTER RETAINS
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