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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 02-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1.Generators US EPA ID No, Manifest 2 Page 1 Information in the shaded areas <br /> 7 -�� Document Nod of is not required by Federal <br /> WASTE MANIFEST S G 5 6 C e < 18W. <br /> enerator a ame and ailing Qdress tate anHast Document Num r <br /> F: 84505196 <br /> B.State Generator s ID <br /> 4. Generator's Phone ( r'C'� <br /> ranarator*r �ny ame U EPA ID Number i tate ransporter s - <br /> 17 <br /> 4r F U �A. > n �. « ram• Friona <br /> 7. Transporter 2 company Name B. US EPA ID Number E.5tine Transporter's 10 <br /> ro s Phone <br /> e gnat acflity Name and SiteAddress 10. US EPA 10 Number GStaft s ID <br /> �jCICZc�� Si ti < cif 0 C) b <br /> C�_ 7H.Fas Iry a Phone <br /> 12.Containers 13, 14. <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class, and ID Number Total Unit Wast1. <br /> e No. <br /> 0 No. T Quantity <br /> E a <br /> N / / <br /> e (ii�.� <br /> r_ A b. <br /> T <br /> 0 <br /> R <br /> C. <br /> d <br /> x <br /> x -. s ry, s, ,�::_ ra- _ - KMandling Codec Waros <br /> F <br /> 'at Handling Instructions and Additionaln ormatlon <br /> 16.GENERATOR'S CERTIFICATION:I <br /> hereby declare that thecontents,of this consignmentare ully and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and we in all respects in proper condition for <br /> transport by highway according to applicably interneyp0at and natio I govern�negtgl regulati s <br /> �iV7 rtr� C'i� — 7- U f Date <br /> Printed/Typed Name / Sig at , p Mont Day Yaer <br /> e/ 8 <br /> T 17.Transporter 1 Acknowledgemem of Receipf of Materials Date <br /> R <br /> A Print Na Signa Monrh Dsy Yser <br /> N <br /> _ a <br /> 1.8..Trarsporteir 2_Ackrwwledgement. or Receipt�raf <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> a <br /> 19.Discrepancy Indication.Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I20.Facility Owner or Operator: Cornification of receipt of hazardous materials covered by this manifest except as noted in <br /> Y hem 19. Date <br /> j Print n" nstu Month ey ear <br /> A&I ri—tolil Anil / IV <br /> White: TSDF SENDS THIS COPY TO DOHS WRHIN 30 DAYS <br /> DHS 5022 A li/64) TO: P.O. Box 3000, Sacramento, CA 95812 M W41.EPA 8700.22) <br />