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Servi <br /> es <br /> State of Callfornla—Health and Welfare Agency Divisi• e • Department of Health <br /> Tpxlc Substances Control Division <br /> Sacramento,California <br /> Pleasep"M or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS Generators o. Manifest age Information in the shaded areas <br /> Do tyn N of iawnot required by Federal <br /> WASTE MANIFEST C A D 9 8 1 1 5 3 9 8 vw v� <br /> Generator's3. Name and Mailing Address A51a a �^i a ment Number <br /> California Dept. of Transportation is x"13 <br /> 1976 E. Charter Way, Stockton, CA 95201 B.StateGenerator's ID <br /> 4. Generator's Phone ( 209 1 935-2076 ' <br /> 5. Transporear I Company Name 6. US EPA ID Number C,State ransporter's 10 7o 6 7- <br /> oz-00L y+ so [OC K C. A. X. U 0. o. a 9. 41( d Z D. ransporter's hone 9091 Z63 4 <br /> 7. Transporter 2 Company Name US EPA ID Number . tate ransporter's ID - <br /> F. iansponere Phone _ <br /> 9. Designated Facility Name and Site Address 0. US EPA 10 Number tateacillty a IU <br /> Chem Waste Management 'l-p c)o C^ 4 <br /> 35251 Old Skyline Road aclitys Phone _ <br /> Kettleman Hills, CA 93239 IC A T 0. 0 0 6 4 6 1. 1 7 (209) 366-9711 <br /> 12.Containers 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 &RIXXifMi(X9(d0IR7(XBItdXMiXO(X1IIg!(d(YXitiI�IXXXXRRd(ilYld(X1FR8&ISI <br /> E Hazardous Waste Solid, N.O.S. . ORM-E, NA 9189 001 DT 6 Y � �l <br /> R <br /> A b <br /> T <br /> 0 <br /> R <br /> C. <br /> d. <br /> J_ Additional.Deftcrlptions a Merials Listed K.Handling Codes for Wastes isleI Above <br /> Soilo0ta>Dtatetwith diesal �fuel. Profile 9f26251 � D <br /> i" 3 <br /> YX' 33Y`55ti4 <br /> SpecialHandling instructions-an I dditional Information <br /> I :Iherebydeclarethatthecontentsofthis consignmerlt ere ully and accuratelydescribed <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 /> Printed/Typecl Namgr Signature/� 'I- 1 .l_ l Mont h Day YJ <br /> I <br /> T 17,Transporter 1 Acknowledgement of Receipt of Materials Date <br /> RMonth Day Year <br /> A Printed/Typed Name Signature <br /> "s �,� tC �FL0 'U, I -0 <br /> p <br /> Date <br /> 0 18.Transporter 2 Acknowledgement or Receipt of Materials <br /> R Si nature Month–5--yyear <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 /> I 20.Facility 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 /> Inted yped Name Signe re month Day Year <br /> 11) <br /> DH5 8022 A(7/84) &fall <br /> (EPA 8700-22) Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />