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State or Cadlfornla—Health and Welfare Agency • a '? • Department of Health Services <br /> Toxic Substances Control Division <br /> Sacramento,California <br /> Please�print or type. (Form designed for use on elite 0 2-pitch)typewriter.) <br /> UNIFORM HAZARDOUS enerators o. Doc anesNo of Page ;snotn in shad Federal <br /> WASTE MANIFEST C A D 9 8 1 1 5 8 9 6 3 �I �/ <br /> 3. enerators ame and MailingAddress A, taje,.M i1P L D ent Number <br /> 14 <br /> California Dept, of Transportation S � <br /> 1976 E. Charter Way, Stockton, CA 95201 e. tateGenerator's ID <br /> 4. Generators Phone ( 209 1 935-2076 <br /> b. ra nsporser 1 Company Name US EPA ID Number tate rensporter's ID Q 6 <br /> 63 ' Z <br /> Wil, Vr =!� /SOC K- C.A.X .0. ().D.0 . �. y. ! �6.L D. ransporter's Phone `Gl 04 <br /> 7. Transporter 2 Company Name US EPA ID Number E. tate Transporter's ID _ <br /> ransporter's Phone <br /> 9. Designated Facility Name and Site Address 1 US EPA ID Number . tate aciliry's D _ - ' <br /> Chem Waste Management (��1 65 <br /> 35251 Old Skyline Road acihty s Phone . <br /> Kettleman Hills, CA 93239 IC. A. TO 0. 0 6. 4 6. I 1 7 (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 No. T e Quantic Waste No. <br /> N Hazardous Waste Solid, N.O.S. , ORM-E, NA 9189 001 DT 01 Y MaIPIA <br /> E <br /> R <br /> A b. <br /> T <br /> 0 <br /> R <br /> C. . <br /> d. <br /> J AddOescdpoopor y eterials UsteA K.Handling Codes for Wastes- tste ve <br /> itional a ' <br /> Soil eanfia ►tna'tesirltpGieselfuei. Profile-#F26251 v �. <br /> Pi <br /> 15. <br /> . i <br /> a x � <br /> Speciar-Handling Instructions an dditionaln ormation <br /> =by <br /> R I TI N:Iherebydeclarethat the contents ottIn co trial erK"pr.p,� <br /> escribedping name and are classified,packed,marked,and labeled,and are in anion fory according to applicable international and national governmental regDateSignatureMonth Day YearPrin['d/Typadame, / .J . .DateT 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> n Printed/Typed Name SignatureMonrh Day Year <br /> "sNt I'jo N1 I C H e C t <br /> P Date <br /> 0 18.Transporter 2 Acknowledgement ori Receipt of Materials <br /> RPrinted/Typed Name - - Signature Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication.Space <br /> F <br /> A <br /> C <br /> i <br /> L <br /> I 20.Facilityy Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T, <br /> rItem 19. Date <br /> Month Day Year <br /> Signature / �� <br /> Printed/Typed Name / - �; <br /> DHS 8022 A(7/84) //m saw <br /> (EPA 8700-22) Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />