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'yy f Department of Health Services <br /> `ate of California—Health anti Welfare Agency �.J. t/ ,i �,,� Toxic Substances Contrul Division <br /> Sacramento,California <br /> Pisase print or type. (Form designed for use on elite(12•pitch)typewriter.) <br /> UNIFORM HAZARDOUS 7-71. Generator's US EPA ID No. ani est 2- Page 1 Information in the shaded areas <br /> Document No. of is not required by Federal <br /> WASTE MANIFEST �.�� law. <br /> 3. Generator's NaSne an Mallin Address A-State Mrs fest s� entnt Number <br /> s0. A 4'k0u� t ;;..lc�t.;Ni'...rd. ��<�"•�— B.State Generator's ID <br /> 4. Generator's Phone( T 0•1 ) I A "r � _ _.-. — <br /> ih. US EPA ID Number C.State Transporttar's ID <br /> 5. Transporter 1 Company Name <br /> .J' D.Transporter s Whone A.t ,; , ;?4 r. <br /> Transport 2 Cornpany'Name 8. US EPA ID Number E.S4aate Transporter's Ifs <br /> I. _-- . F.Transporter's Phone <br /> 9. Designated Facility Nameand Site Address 10. US EPA ID Nurnber G.State Facility's ID <br /> E <br /> "H. `ac Iity s I tlCsre9 <br /> lj <br /> i 12.Containers 13. 14. <br /> I f I. <br /> 1 11.US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) Total Unit <br /> No. Type Quantity 0/vol Wat?-„ to W14o. <br /> N a <br /> A b. ° iI <br /> C. <br /> i <br /> d. <br /> Additional Descriptions for <br /> /yMaterials Listed .Above K.Handiing Codes for Wastes Listed Above��' <br /> �_`�"+„ xw h � �. N `��w i ��.•..•iii i-.� r»r:w�r fit i.:. tc?ti _ a� � /C~ <br /> 15.Special Handling Instructions and Additional Information ' 1 J tJr/ L- J ( '�,y ,n <br /> Tt,,( <br /> it <br /> ) - n K I h� .)�(~ t t i�. �., 1 A A f <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 /> i for transport by highway according to applicable international and national governmental regulations, <br /> Date <br /> Printed/Typed Name TSignature Month Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> A Printed/Typed Name -- Signature — Month Day Year <br /> j o 18.Transporter 2 Acknowledgement of Receipt of Materials Date <br /> Day Year <br /> PrintedlTyped Name Signature Month <br /> E <br /> 19. Discrepancy Indication Space <br /> F <br /> L 20.Facilityy Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> I Item 19. --_--F Date <br /> j Y <br /> Printed/Typed f yped Name Signature l!Month Day Year <br /> 1 <br /> DHS 8022 A(11184) YELLOW: GENERATOR RETAINS 8489641 <br /> CEPA 8700-22) <br />