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State of Cailfornla—Health and Welfare Agency Department of Health Services <br /> Toxic Substances Control Dlvislon <br /> Sacramento,Callfornla <br /> Please print or type. . (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS enerators o. Manifest age Information in the shaded areas <br /> WASTE MANIFEST CAD 9 8 1 1 5 8 9 8. 3 Document No. of f laWnot required by Federal <br /> Generator'sU1 550 3. Name and Mailing Address A,Stap vManifest, OQculment Number <br /> California Dept. of Transportation �t ,: -:a 6 U <br /> 1976 E. Charter Way, Stockton, CA 95201 B.StateGenerator's I <br /> 4. Generator's Phone 1 209 ) 935-2076 <br /> 5. Transporlier 1 Company Name b. US EPA ID Number C.State ransporter's ID <br /> . ransponers Phone _ <br /> raps -r omDeny ame US EPA ID Number tate ransporter's 1 <br /> F.Transporter's Phone <br /> Designated Facility Name and Site Address 1 . US EPA ID Number G.State Facilitys-I <br /> Chem Waste Management -G <br /> 35251 Old Skyline Road . acilitys Phone _ <br /> Kettleman Hills, CA 93239 IC A T 0 0 0 6 4 6 1 1 7 (209) 386-9711 <br /> 12.Contamers 13. 14. <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class, and ID Number) Total Unit Waste No. <br /> No. Tyne Quantityd <br /> G <br /> N Hazardous Waste Solid, N.O.S. , ORM-E, NA 9189 001 DT �� Y .JMldll <br /> E <br /> R <br /> A b <br /> T <br /> 0 <br /> R <br /> C. <br /> d. <br /> J. Additional iptions or eteriela Elated K.Hantlling Codes for Wastes Llst ve <br /> Wtth�dtesel� tuel#, Profile #F26251 <br /> patio an ing nstructlons and itional n ormation <br /> 1 N R ATI N:I hereby declare that the contents of this consignment ere ully and accuratelydescribed <br /> above by proper shipping name and are classified,packed,marked,and labeled,and are in all respects i It proper condition for <br /> transport by highway according to applicable international and national governmental regulations. <br /> Date <br /> Printed/Typed Name Signature r- -- Month Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials -- Date <br /> R Signature Month Day Ye <br /> A Printed/Typed Name g i"t <br /> N . <br /> P P <br /> 0 18.Transporter 2 Acknowledgement or Receipt of Materials Date <br /> R Signature <br /> Month Day Year <br /> T Printed/Typed Name g <br /> E <br /> R <br /> 19. Discrepancy Indication.Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facilityy Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted In <br /> T <br /> v Item 19. - Date <br /> Si na a Month Day Year <br /> Printed yped Name r 9 / ,, <br /> l <br /> (EP 8022 A () eat Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS 8B6't <br /> TEPA 9700-22) <br />