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SUB of Odllfornla—Health and Welfare Agency Department of Health Services <br /> `r �L 'f ;',�� ut 0- Toxic Substances Control Dlvlslon <br /> Sacramento,California <br /> Plea"print a type (Form designed for use on elite(12-pitch)"n,,nef) <br /> UNIFORM HAZARDOUS 1.Generators US EPA ID No. Manifest 2.Page I Information In the shaded areas <br /> WA .'i 7/ �)J �� 7 Document No. of isswnot required by Federal / <br /> STE MANIFEST <br /> neretur a Name and Mailing ddress A.Stato rare <br /> umber <br /> 6W <br /> - — _ . tate otesrNor• ' <br /> 4. Generator's Phone ( '� / .S '"'' <br /> . � M <br /> n�por mpeny ame6. U _ _umber_/ tate rargporter e IDt <br /> —Transporter7. party Name a. US EPA ID Number rKoisisters <br /> . r s Phone <br /> 9. <br /> - <br /> tgn rt octhry Name a its Address U I Number IdSieft s <br /> H.FecillWo "social <br /> 11.US DOT Description(Including Proper Shipping Name. Hazard Class, and ID Number, 12.Contelners 1 14. L <br /> pPi D Total Unit <br /> a A No. T Ouenti Wads No• <br /> a <br /> A b. <br /> T <br /> 0 <br /> a <br /> C. <br /> d. <br /> Will Wood Alloose Lmorildli"Codiao rw Wood Above <br /> 7S 7 w r�Hev <br /> Handling Instructions and AdditionalInformation <br /> qL-7 C211- <br /> i31 77 /u15 <br /> 16.GENERATOR'S CERTIFICATION:I herebydactarethat them intacthis consignment are fully and accurately described <br /> above by proper shipping name and are classified,pecked,marked,and labeled,and mein oil respects in proper condition for <br /> transport by highway according to applicable international and national governmental regulations. <br /> Date <br /> hinted/Typed Name Siprta[u _J Month Day Year <br /> T <br /> 7 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> M Printed/Typed Name 7� t , Signature �' I -� 1, /i// �i , / Month Day Yeer <br /> Fy- <br /> 0 19.Transporter 2 Acknowledgement or Receipt of Materials Date <br /> Printed/Typed Name Signature Month Day Year <br /> I <br /> 19.Discrepancy Indication Space <br /> r <br /> C <br /> I <br /> I. <br /> I <br /> T 20.Fapliry Ownaf cr Operator: CertiftuUon ipt of receof hazardous materials covered by this manifest except as noted in <br /> nem 8. <br /> y One <br /> Im arra Signature month Day raw <br /> Yellow: GENERATOR RETAINS <br /> DHs eozz A 171— <br />