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Fels al rove rnlo—Neelth and Welfare Agency <br /> See Instructions on 886k of Page S Department of Health Eanulcea <br /> Form Approved type <br /> No.(Form <br /> do3i 039(Expires 9 30t.q and Front of Page 7 Tnalo bebnrences Control Division <br /> pleea*pHnl or type. (Farm 0*sipnsd 10/u*e do Nlfe(12 pdcA lypewrder). S.cumealo,California <br /> UNIFORM HAZARDOUS 1 Qan119101 US EPA ID No. Manifest 2. Pape t Information In the shaded of so <br /> WASTE MANIFEST ( d y6 Q Z Dacam m No. <br /> O 4 0l / le not required by Federal law, <br /> 3, en eters eme en sill dd xae A. Stale Manual u nl IN b r <br /> I�Hof sk e an�W 1� IX;,. , VALLE)' /JVD. O)VIS/UA/ `(J, <br /> /3)_3 S. STOLKTQ/V STh't ET, 4,0D1, CALJfOY!A1,,A <br /> cs �1 9. slave OMentore ID <br /> 4. Generator's Phone(209) 3�bf—080/ 95 y004ISI,9141.31Z 10111 <br /> e <br /> Q 19 <br /> 6 Transporter 1 Company Name 9.. C. elate TneaponH'a 7 <br /> N CX.EM/LAL WASTE A,1AA1AC-F /./ <br /> US EPA ID Number CI 17 11 L9D. nnaponeb nom <br /> 7. Transporter 2 Company Name e. US EPA ID Number EStale Transponar's to <br /> I I f_I I I I I I F. Transtiont PMna <br /> 9. Designated Facility Name and Site Address 10, US EPA 10 Number G. stab Facility'*to <br /> e't/tM/CAL )/VAs'TE 1t4AA1A6'r`7L 17A1r IAIC. <br /> v K,sr7'4EAAA7V /!/LLS f7Ar/L1rP L_IA1712I010161 ��1/ 1 /171 <br /> m <br /> H. Facility's <br /> < /CETT�MA,%1 r1 r), nay i Phone <br /> M� �r <br /> 12. Container. 13. Total 14. 1. <br /> CDC 11; US DOT Description(Including Proper Shipping Name,Hazard Cie.*,and ID Number) Guanlily Unit Waeb No. <br /> C)4 No I Type wtiv 1 <br /> ,Mz <br /> a <br /> G LAC.JFD.QA/JA. T.r7D LvASTE VAYLY stat. <br /> i2C_6ZQAJS <br /> >.00§ N. 010 <br /> O ,/ EPRf Other <br /> (:CC) E b. _.— Y Stela <br /> N R <br /> A <br /> - T -EPA/Other <br /> v D <br /> v R c. <br /> Stare <br /> EPA/Other <br /> UJ d. State <br /> F <br /> Z <br /> U EPA/Other <br /> of <br /> 0 J. Additional Descriptions for Malarial Listed Above K. Panelled Code,lar Westea Listed Above <br /> a <br /> N <br /> s <br /> o <br /> H IS Special Handlmn Instructions and Additional Information <br /> Z, �L = PR0�7�E S/ o -�� 939�9 -ops ? O. for i"1c9 <br /> U 1e, <br /> GENERATOR'S CERTIFICATION: I hereby declare that thecontents of this consignment are fully and accurately described above by proper shipping name <br /> ..I and are classified,packed,marked,and labeled,and are in all respects in proper coaan on for transport by highway according to applicable international and <br /> Nnational government regulations. <br /> op If t em a large quantity generator,I certify that I have a program In place to reduce the volume and tonicity at waste generated to the degree i have determined <br /> -� to be economically practicable and that I have Selected the practicable method of treatment,storage,or disposal cunenily available to nil which mournizes the <br /> present and allure threat to Human health and the environ?:anL OR,if I em a small quantity generator,I have made a good faith effort to minimize my waste <br /> V generation end select.the best waste management method that is available to me end that I can afford.. <br /> Z <br /> U Printed/Typed Name _ Signet Month Day Yeu. <br /> ¢ <br /> VrRFL2 <br /> y <br /> w <br /> wR 17. Transporter 1 Acknowledgement of Receipt of Materiels <br /> a� A Printetl RYp eme Sweeties 'Month Day Year <br /> t <br /> N V <br /> O S <br /> W p IS. ren cner 2 Acknowledgement-of of Receipt of lariats <br /> UT rimed/Typed Name Signature Mon, Day Year <br /> E <br /> 2 <br /> 19. Discrepancy lodicallon.Space <br /> A N.4 - /✓A EPA' 0000. <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest accept as notedin item 19. <br /> �5 T <br /> SF'> y Printed,Typed Name + Signet... .Month Day Yaer <br /> �� �_ 10131OtS7Slo f <br /> S 8022 A(1,ae) Do Not Write Below is Line <br /> �.Ae7u0—xe WLiu:: T)Uh SFNDS THIS COPY.TO.SONS WITHIN 30 DAYS <br /> V,960 Previous edition.are obsolete. <br /> To. A.O. sox 3000, Sacramento, CA 95812 <br /> 03/25/1998 ''ORIGINAL MANIFEST COPY" <br />