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_�!! — yl: .� Y,•Yi. Y`3L _ _. ll. _ _ YLL V.. . - i....L�:.�.._ ,a .....4.".. .,� ..'. .r .... <br /> State of California—Health and Welfare Agency Department of Health ServicesToxic Substances Control Divlelon <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1. Gener tor's US EPA ID No. 11 Manifest 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST l� •A �l.�l •� •t •(. . i ~T/ DaourrrnntN: of Isswnot required by Federal <br /> 3 .13auteraWs Nam8_§0dl <br /> rJ-MIyGlelling Address <br /> �u1 ; AB..SS tate �Manifest Document Number <br /> e <br /> 847 QQ26 <br /> /l � i0h, <br /> h*� 5 (4_4r&tj <br /> `nS at enpa or's I <br /> D7L�sP oe( <br /> 71�91,enren �( � 92��y � J <br /> 5. oogpan ams 8. USEPA D Numja C.State Transporter's <br /> JhC <br /> D.Transporter's Phon - _ <br /> 7. Transporter 2 Company Na V 8. 1 US EPA ID Number E.State Transporter's 19 <br /> . F.Transporter's Phone <br /> 9.1 'Designttigd Fa II y Name and Site Address 10. US EPA ID Number G.State Facliq's ID j <br /> F t, c.11 , uYcrS V4�7Cla <br /> � cil 's Phone <br /> �(',r r ;'G , wp <br /> C 3 �� .0 Pr.�.0 q l°7�� /. 937 z?Vq <br /> 12.Contalne s 13. 14. t <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,end ID Number) No. T Total Unit Waste No. <br /> Type Quantity tt1Vo <br /> R �oct�t�i[c �G�i S� r n:0.5 VI'_ t � �• 315Z- <br /> it <br /> CA I,G 1.(. <br /> A b <br /> T <br /> O <br /> R <br /> C. <br /> d. <br /> CD _ <br /> J. A I I nal Descriptions for Material ' Listed A v J K.Handlin Codes for Wastes Listed Above <br /> N l g <br /> tD P} Vfs( "rVttiff�a y4l }x21 <br /> CD X11 v`J <br /> 1 e 1�.1� ✓ <br /> Nr15.Special Handling Instructions and additional Information <br /> Yl <br /> I <br /> 18.GENERATOR'S CERTIFICATION:I hereby declare that the crtentsvtthiscop_signment are fully and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and are Inr� 11 4 acts In proper condition <br /> for transport by h ghway according to applicable International and nail gove meth I egulatlolls. <br /> Date <br /> Pr)ntedlTPed Nme SignatW Month Day Year <br /> {r( r �r f 7'ci "-/ <br /> R 17.Transporter 1 c nowieogerdent of Receipt of Materials Date <br /> N -;ZTyped Na / Si net re - Month Day Year <br /> P e�ou 9 0 <br /> e 18.Transporter 2 Acknowledgement of Receipt of Materials Date <br /> E Printed/Typed Name S ature Month Day Year <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> 20.Facility Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted In <br /> i Item y9. <br /> T <br /> Date <br /> y Printed/Typed Name <br /> Signature Month Day Year <br /> DHS 8022 A(11184) White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (EPA 870022) <br /> TO: P.O. Box 3000, Sacromento CA 95812 8489641 <br />