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t <br /> Department of Health Services <br /> S! to of C�-.itornla—Health and Welfare Agency Toxic Substances Control Division <br /> Sacramento,California p <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. ani est 2. Page 1 Information in the shaded areas <br /> Al WASTE MANIFEST .C.A 7 - 4i , .Document NIs not required by Federal <br /> Of law. <br /> 13. Generator's Name and Mailing Address A.St to Ma fe t u ent Number <br /> P.O. X50395 4 <br /> �r n stoc3 ', CA 95201 I�S Slate Generator's i <br /> BOX <br /> 4. r taenera ors Wonetlr2ng ) __ l <br /> 5. Transporter 1 Company Name 6. US EPA ID Number 1C.State Transporters <br /> �. D.Transporter's Phone <br /> 7. Transporter 2 Company Name B. US EPA ID Number E.State Transporter's ID �+- <br /> . . . . . . . . . F.Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G.State Facility's ID <br /> I <br /> South Bay Chemical Phone��;"�•--- — l_. <br /> 731 Rem Lwie <br /> 12.Containers 13. 14. i <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total Unit I. <br /> No. Type Quantity t/vol Waste W. <br /> a .h ,,J W J t..• <br /> fI N <br /> 7;2 I <br /> E � <br /> A�b <br /> T <br /> Irt ✓firG' r .7 .(U '- <br /> C. <br /> d. <br /> 61 <br /> I. Additional Descri for Materials Listed Above E K.Handling Codes for Wastes Listed Above <br /> 115. Special Handling Instructions and Additional Information <br /> i <br /> ' <br /> �15 GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described <br /> atove 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 /> l PrintedlTyped Name 7-7 Signature Month Day Year <br /> - 17, Transporter 1 Acknowledgement of Receipt of Materials Date <br /> A Printed/Typed Name Signature - Month Day Year <br /> N I <br /> io 18.Transporter 2 Acknowledgement of Receipt of Materials Date <br /> fl <br /> r <br /> Printed/Typed Name Signature Month Day Year <br /> ' E <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> 20.Facilityy Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T 1 Item 19. Date <br /> I v PrintedlTyped Name Signature Month Day Year <br /> LL <br /> L, , -022 A(11/84) YELLOW: GENERATOR RETAINS 84 89641 <br /> (EF r.8'00 22) <br />