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State of California—Health and Welfare Agency • • Department of Heart Services <br /> Toxic Substances Control <br /> Division <br /> Sacramento,California <br /> Please print or type. (form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM-Hh4ZARDOUS enerators o. p� an�lstest age normation in the shaded areas <br /> WASTE MANIFEST <br /> CAD 9 8 1 1 5 3 9 8 D'? J'Y °7 of / isnotrequired by Federal <br /> Generator's3. Name and Mailing Address tee,Mg�# .,Doc ment Number <br /> California Dept, of Transportation ITSTI,TI, y <br /> 1976 E. Charter Way, Stockton, CA 95201 tate enerators l <br /> 4. Generator's Phone ( 209 ) 935-2076 <br /> ranspower 1 Company ame US EPA ID Number tate ransporter s IDic <br /> '!.. / / / ✓. r,.- .f.G ;L. . rens iters Phone <"-7 <br /> 2+r i� r �- �. � Po �t. 4.. <br /> Transporter Company Name 8. US EPA ID Number tate ransporter's ID <br /> . . ranW ter's Phone <br /> Designated Facility Name and ite Address 10. US EPA ID Number tate Facility's ID <br /> Chem Waste Management ( , OU <br /> 35251 Old Skyline Road H. aoi tys hone <br /> Kettleman Hills, CA 93239 D. A. T. 0. 0. 0. 6. 4. 6. 1. 1. 7 (209) 386-9711 <br /> 12.Comamers 13. 14. 1. <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class. and ID Number Total Unit Waste No. <br /> No. T e Quantity <br /> G <br /> N Hazardous Waste Solid, N.O.S. , ORM-E, NA 9189 001 DT Y NA <br /> E �;, f s <br /> AllR <br /> A b <br /> T <br /> 0 <br /> fl <br /> C. <br /> d. <br /> J AddltlonaV iptic, or aterlajs Usted K.Handling Codes for Wastes tste ve <br /> Soi � C � fEhSlfesul 'fuel,, Profile BF26251 <br /> pecla an ling nstructlons and dditional Information <br /> N R 1 TI N:I herebydeclere thatthe contents of this consignmerrare ullyand accurately described <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. Date <br /> Signature i;' / Month Day Year <br /> Printed/Typed Name y ' <br /> Date <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> /Printed/Typad N 1"B Signature Month Day Year <br /> e '1 C C iC� C �t-1 /r '1 <br /> P Date <br /> 0 18.Transporter 2 Acknowledgement Receipt of Materials' <br /> R Signature Monrn Dey Year <br /> T punted/Typed Name <br /> E <br /> R <br /> 19.Discrepancy Indication.Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as note In <br /> T <br /> Item 19. Date <br /> Print ypSign fure Month Day Year <br /> - ed ad Name - _ <br /> .� <br /> DHS 8022 A(7/84) 81 89611 <br /> (EPA 8700-22) Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />