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T A See Instructtlons on back of paC Department of Toxic Substances Control
<br /> State of California—Environmental Protection Agency 7� Sacramento,California
<br /> Farm Approved OMB No.2050-0039(Expires 9-30.99 '
<br /> Please print or type. form designed for:we on elite F 12'Pilehf
<br /> .1. Generator's US EPA ID'No.� _ Manifest Document No. .2, Page 1: _ Information in the shaded areas
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<br /> is not required by Federal law,
<br /> UNIFORM HAZARDOUS of
<br /> WASTE MANIFEST i "j t7r
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<br /> 3. Generator's Name and Mailing Address
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<br /> A. Generator's Phone �'t-„+4 s -1
<br /> ,n C State Transporters]Q[Reserved -�� *' t t s
<br /> �� 6 US EPA'ID Number" E
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<br /> 11. US DOT Description line€uding Proper.Shipping_Name,Hazard Class;and IQ Numbed Na Tye r Quantity WrfVol I YVaste Number - - f
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<br /> 1 G. GENERATOR'S CERTIFICATION: I hereby declare that theconten s of this consignment are fully and accurately described above by proper shrpprng name and are classified,packed, 1
<br /> marked;and labeled,and aro-in all respects in proper condition-For transport y highway according to applicable international and national government regulations. `1
<br /> =+ wa a re'ram in lace to reduce the valume'and tonicity of waste generated ra the degree 1 hove defermlmcl,to be.economically
<br /> If l'am o large quarts generator;I certify"that I ha p p
<br /> N practicable and that 1 have selected the procticable method of Ireatmemr,storage,or disposal-currently-ovailable to me which minimizes'rh the bear and Fu anogern t to Kumon health...
<br /> and the environment;OR'-if I am o small quantify generator,I'have made a'good.fnitl+effort to minimize-iny waste generation and,select itis best wash management method that'is_
<br /> ac 'available to me and that I can afford. r . ` '
<br /> re ,"Day .Year
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<br /> Printed/Typed Nome { y _
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<br /> t (5 T 17. Trans orter 1 Acknowledgement of Receipt of Mciterials "-
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<br /> T ed Nome S+ nater
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<br /> Op 18. Transporter 2 Acknowledgement of Receipt of Materials Month Day, Year
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<br /> U 19. DiserepariryIndication$pace
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<br /> " 20. Facility Owner"dr Operator Certification of receipt of hozordous'materrals covered b„thrs moniFest except as noted+n Item 19'. Month Da Year .
<br /> T. Printed/Typed Name Signature y
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<br />{ DO NOT.WRITE.BELOW THIS LINE
<br /> DISC 8022A 111991 ` Yellow: . GENERATOR RETAINS
<br /> :: EPA 8700-22
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