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State of California-Health and Welfare AgencyDepartment of Health Services <br /> Form Approved OMB No.2050--0039(Expires 9.30-aa) Toxic Substances Control Division- <br /> Please rint ort e. Form desi ned for use on elite IA @writer). . Sacramento,California <br /> UNIFORM HAZARDOUS 1I. Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areae <br /> WASTE MANIFEST Q p p Z 0 ocument No. of / is not required by Federal law. <br /> 3. Genc'La 4 �• and Mailing Address A. State Manifest Document Number <br /> I� au � � a�c� 87505651 <br /> L C� B. Stab Generetoes W <br /> 4. Generator's Phone a-1) <br /> S. Transporter 1 Company Name 6.n US EPA ID Number C. State Transporter's ID <br /> (.�L)V�� ` (., 6 / D. Traneponer'e Phone qj j,;- <br /> 7, Transporter 2 Company Name 6. US EPA ID Number E. State Transporter's ID <br /> F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> C--Q-C-1y'-,s.ra,�r)1 T,N C, <br /> ass !'n•^"' aW0 H. Facility's Phone <br /> Cs- e ,i,) o S 6 3 `!)S q3T- 1393 <br /> 12. Containers 13. Total 14. I. <br /> 11. US DOT Description(including Proper Shipping Name.Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt/Vo <br /> a <br /> State <br /> N CdY�C Lr•x* RriG U, Ot�i l� (,SA5T� G7 Ai Q -� OQO P EPthey <br /> N�►'6 <br /> E b. Slate <br /> R <br /> A <br /> T EPA/Olhef <br /> RC. State <br /> EPA/Other <br /> it. <br /> State <br /> EPA/Other <br /> JAdditional Descriptions Material?Listed Above K. Handling Codes for Wastes Listed Above <br /> CMPTl .OcQ6k / b. <br /> weih /8o <br /> ryas Aay-FtE Ernp'ry <br /> 01 <br /> T*,-k 1163) 1C-e-5) w,f4% a> cbs /J/)7 -Fc� d. <br /> 15. Special Handling Instructions and Additional Information <br /> f/",o rhrq-r t G to a(,s &j-� pa- <br /> Nc��co I(LA- //tea-fo IWe- <br /> 16. <br /> GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> international and national government regulations. <br /> If I am a large quantity generator, 1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have <br /> determined to be economically practicable and that I have selected the practicable method of treatment. storage, or disposal currently available to <br /> me which minimizes the present and future threat to human health and the environment: OR. if I am a small quantity generator, I have made a flood <br /> faith effort to minimize my waste generation and select the best waste management method that is available to me and that 1 can afford. <br /> Printed/Typed Name Signe a Month Day Year <br /> WI(OZ05 430/rir0 ' 10 1Sj 11718 S <br /> R 17. Transporter 1 Acknowledgement of Reqkv�$I Mat Is <br /> A Printed/Typed Name Z t Sign re Month Day Year <br /> N <br /> S (G tV 061 / <br /> 0 1 . Transporter 2 kicknowledgement of R1 Meta <br /> R Printed/Typed ed Nama <br /> 7 yp Sip re Month Day Year <br /> E <br /> 19. Discrepancy Indicalion Space <br /> F _r7 <br /> A <br /> C <br /> 1 20. Facility Owner or Operator Codification of receipt of hazardous materiels coveretbpffiieanilesf except as n d in he <br /> TPrint / yped Name Sipnatur Month Day Year <br /> aN atm cor <br /> OHS 6022 A 21/87) -o, C � , I LICTIONS ON THE BACK <br /> EPA 8700---22 V'lir,tz: TiDF ,EN"::", TIPS COPY I�_ G�tiS 1'+IT'J:� ..0 LASS <br /> (Rev.9.66) Previous editions are obsolete. ;c: i'.v. !:::. ...;�J, 'cIramonto, Cit 9",812 <br /> IN CASE OF AN EMERGENCY OR SPILL, CALL THE NATIONAL RESPONSE CENTER 1-800-424-8802; WITHIN CALIFORNIA CALL 1-800-852-7550 <br />