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• • Department of Health Services <br /> Toxic Substances Control DwIslon <br /> State'of California—Health and Welfare Agency Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) an Bat 2. Pa 8 1 Information in the shaded areas . <br /> UNIFORM HAZARDOUS 1. Generator's US EPA 10 11, Document No. 9 is not required by Federal <br /> WASTE MANIFEST of law. <br /> 3. Generator's Name and Mailing Address <br /> State Manifest-Document Number <br /> _ r r'. <br /> B.State Generator's ID <br /> 4. Generator's Phone <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C.State Transporter's ID <br /> D.Transporter's Phone <br /> 7. <br /> Transporter 2 Company Name 8. US EPA ID Number E.State Transporter <br /> 's ID <br /> F.Transporter's Phone <br /> r 9. Designated Facility Name and Site Address 10. US EPA ID Number .State Facility's ID <br /> t 7jii� ; 776 <br /> H.Facility's Phone <br /> 12.Containers 13. 14. 1_ <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total unit Waste No. <br /> No. Type Quantity tivol <br /> G / <br /> N <br /> E <br /> R <br /> A b <br /> T <br /> G <br /> R <br /> C. <br /> d. <br /> DOK.Handiing Codes for Wastes Listed Above <br /> J Additional Descriptions for Materials Listed Above <br /> '17, <br /> . Yf q{,kSfYJA�� <br /> 0') tf Y <br /> t.(, <br /> 15.Special Handling Instructions and Additional Information <br /> 00 <br /> 16.GENERATOR'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 <br /> for transport by highway according to applicable International and national governmental regulations. Date <br /> Printed/Typed Name Signature Month Day Year <br /> Date <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> A Printed/Typed Name <br /> Signature Month Day Year <br /> N <br /> s <br /> Date <br /> o 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> R PrintedlTyped Name. Signature Month Day Year <br /> E <br /> R <br /> 19. Discrepancy Indication Space r, I a OoZ I <br /> GCr,lru ! yrJ ,l cY. �� u J Slcn �3 Cw,, f� [c' <br /> o/ GNr <br /> C11 i..,c 'f_ <br /> C <br /> 20.Facilityy Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as notedin <br /> Date <br /> I Item 19. <br /> TMonth Day Year <br /> Y Printed/Typed Name Signature /, l <br /> GREEN: HAULER RETAINS e4 B9641 <br /> DHS 8022 A(11/84) <br /> (EPA 8700-22) - - <br />