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Department of 1-,+.+ . <br /> State of Californ* ;-Health and Welfare Agency - �1 _ _ Toxic Substances Con'r t'_A, r.•' <br /> Sacramento,t,�!,f, <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No -r 0"'t- dnl Wit.. 2. Page 1 Information in the shaded ar a <br /> octjrneni No. is not required by Fe•� <br /> WASTE MANIFEST I-C •A. D 0 0 9. 1. 7 a 6 °f * Ia'v - --- <br /> 3. <br /> 3. Generator's Name and Mailing Address _ A:3tate MannfRst Document Number <br /> Ogden Foods Pc4t 50'55 ISS 0,-E P Wta <br /> PC) F1C`X DratR3r .T Stcd7 tcm, CA 95131 �eneratar s ID <br /> 4. Generator's Phone(209 ) 946-4123 _ <br /> 5. Transporter 1 Company Name 6. US EPA_!^Numbers ,C.S:at Tratsporter's ID ? (,Kid <br /> south Bay chemical Co. Inc I. C •A •D 0 6 1. 2. 1. 55 •') .4 4D.T anVort4r's Phone 0-01-1 <br /> 7. Transporter 2 Company Name 8. US EPA•ID Nombei " i C.S+at�ape,�-.)rter's ID <br /> L . . . . . . . . . F Transporter's Phone _- <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number 1G.State <br /> Facility's ID <br /> South Bay Ch�r�ical Co. , Inc x,04 731 Ffn2 izme _ ( Phone <br /> Cilz�_CA 95020 I'C •P. -D 05.1• L . r - - <br /> 12.Containers 13. -44 0 14. I j <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total Unit Wa,te No. <br /> No. Type Quantity tivol _ <br /> G <br /> E a. ,r1 <br /> N / <br /> R 1. fIC"'V (_C,;' 'i.'C�. '^( �/ /Yrs) ;1 .� .1_ <br /> C. <br /> �' -- <br /> d. > 7` <br /> 00 1 - <br /> CV J. Additional Descriptions for Materials Listed Above IL,19an�4illg Codes for W`s#tes Listed Abo, <br /> ,� � a <br /> w ,`y <br /> a t T <br /> '44' 15. Special Handling Instructions and Additional Information <br /> 00 <br /> i r : ? <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. <br /> Date <br /> Printed/Typed WarpelC Signature; �.. Month Day Year' <br /> If <br /> t 17.Trarlisporter 1 Acknowledgement of Receipt of Materials j _ Date <br /> A PriptedlTyped Name Signature Month Day Year' <br /> N <br /> 5 <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials ! r Date <br /> A Printed/Typed Name Signature Month Dav Year I <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> 20.Facility,Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in _— <br /> T 1 Date <br /> rint lTy ed (0Sign t re Month Day <br /> r <br /> �J <br /> DHS 8022 A(11184) YELLOW- TSDF SENDS THIS COPY TO ENERATOR WITHIN 30 DAYS <br /> 9a�jggai <br /> (EPA 8700.22) <br />