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------------- --------------- <br /> State of California—Health and Welfare Agency • • Department of Health Services <br /> Toxic Substances Control Division <br /> ._ Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS � enerators o. antes[ . age n ormatlon in the shaded areas <br /> WASTE MANIFEST Document No. of 1 lawnot required by Federal <br /> enerators Name and Mailing Address A$tate„Manite$t.Do; ment Number <br /> California Dept, of Transportation <br /> 1976 E. Charter Way, Stockton, CA 95201 6. tate enerator's I <br /> 4. Generator'sPhone ( I <br /> b. ransporaer 1 Em any ame 6. US EPA ID Number tate Transporter'a ID <br /> (,lit, so lenc. ,,. ) ransporter's Phone <br /> 7. Transporter Company Name 8. 'US EPA ID Number .. tate ransporter's ID - <br /> . . . . . . . . . ransporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G.StateFacility's-ID ` <br /> Chem Waste 14anagement <br /> 35251 Old Skyline Road tI s h°ne <br /> Kettleman Hills CA 93239 IC A T 0 0 209 386-9711 <br /> 12.Containers 13. 14. 1 <br /> 11. US DOT Description/including Proper Shipping Name,Hazard Class, and/D Number Total Unit Waste No.: <br /> ° No. Type Quantic <br /> E a. NA <br /> E Hazardous Waste Solid, N.O.S., OR&1-E, NA 9189 001 DT O Y <br /> R <br /> A b. <br /> T <br /> 0 <br /> R <br /> L. <br /> d & <br /> J.'Additional 1 ono W atenela at K.Handling Codes for Wastes Listedve <br /> S t 4►�� 4 s h diesel fuel. . Profile /F2626115. U <br /> Special andhng nstructions rand dditional Information <br /> 11 �2 <br /> 16.GEN ERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and 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. <br /> Date <br /> Printed/Typed Name Signature — I Month Day Year <br /> — f, r r <br /> ransp <br /> r 17.Torter i cknowiedgement of Receipt of Materials Date <br /> A Printed/Typed Name Signature Month Day Year <br /> PDate <br /> 0 18.Transporter 2 Acknowledgement or Receipt of Materials <br /> R <br /> T Printed/Typed Name Signature Mourn Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication.Space <br /> F <br /> A <br /> C <br /> I <br /> E <br /> 20. Facilityy Owner or Operator: Certification of receipt of hazardous materials covered by this manitest except as noted in <br /> `T, Item 19. _ Date <br /> Printed yped Name --� ._ Sign ur - Month Day Year <br /> _ l <br /> I A.7 1/) <br /> DHS 8022 A 0/e4) <br /> (EPA 8700-22) Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS 84896+1 <br />