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Department of Health S«r <br /> State of Cel ifornia—Health and Welfare Agency Toxic Substances Go'ilr-.1 I=,'l.occ <br /> Sacramento,Calitorme <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1. �enP�^' r'� US EPA ID No. an est;: 2: Page 1 Information in the shaded an:as <br /> 1Documenl-No, rs not required by Federal <br /> WASTE MANIFEST ^ n �+ 3 . . . of <br /> 3. Generator's Name and Mailing Address n1� ^ A.State Manifest Document Number <br /> Ogden FoOdS PO f 50395 �•I Ir b .r;�,; I '? o8A&52743 <br /> P. 0. Box IXawf-%x J Stocktoin, CA 9201 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 IDSouth Bay <br /> r0. a . D.I'ransporter's Phon { 4R—JA74 <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E.State Transporters C) <br /> . . . . . . . . F,Transporter's Phone__ <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G.State Facility's ID <br /> South fay Chemical Co. , In . —^ <br /> H.Facility's Phone <br /> 731 Rent Lame <br /> r, - ---� <br /> 2. on ainers <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Class,and ID Number) 1 Total Unit Waste No. <br /> No. Type QuantityWt/Vol <br /> E a. <br /> p �,r �: i f /,7 ?c.N�`✓,��Jr�J -_ _•r"U ! - --•Ill <br /> t;t. <br /> o b ) � ze <br /> ') ) <br /> c. <br /> --I <br /> d. <br /> M `-- K.Handlin Codes for Wastes Listed Nuove 1 <br />� J. Additional Descriptions for Materials Lister: Above � g i <br /> 15. Special Handling Instructions and Additional Information <br /> CO <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, Yga/ <br /> . <br /> r 17. Transporter 1 Acknowledgement of Receipt of Materials Date <br /> RSi natu e i Month qty YBar <br /> A Printe ed Narpe61 <br /> J., <br /> r <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials Date <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> f <br /> F <br /> A <br /> C <br /> 20 <br /> it.FaDate <br /> or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in __ <br /> 11 Date <br /> Y � PrinLe d m ignature Month Da Year <br /> DHS 8022 A(11184) YELLOW TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS 84 h4,;;,. <br /> (EPA 8700-22) <br />