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Department cf Health Ser;Ices <br /> St,,oe of California—Health and Welfare Agency Toxic Substances Control Division <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) informatiorl in the Shaded areas <br /> 1. Generator's US EPA ID No. ani est 2. Page 1 <br /> UNIFORM HAZARDOUS Document Na. is not required by Federal <br /> WASE MANIFEST _. y><: ;: 4 i.; of law. <br /> 3. Generator's Name and Mailing Address A,State MariLiest urr+8fft urnt36r <br /> i -�, _ 652 <br /> 6 A'n'r t=r a >�*�-... B.State Generator's ID <br /> �4. Generator's Phone( <br /> j 5. Transporter 1 Company Name 6. 7US EPA ID Number C.State Transporter's ID.� '"`1..,) �/ rfa'1sCirter'sA Phone ��.el�+♦r�g C.� <br /> 111 7. Transporter 2 Company Name 8. US EPA ID Number E Stat�> Ttansporter's� <br /> -.Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G.State Facility's ID <br /> n `�\ �`K?� !_ ,• � H.Facility's Phone <br /> •�....�.,�- <br /> t 12.Containers' 13• 14• I <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and!D Number) Total unit Waste No. <br /> No. Type Quantity tivo <br /> fF. a.W:t:>':a.. tt��..� ,� -�ti.i`� :-,-.,�t `� ;�:�.:� �/til `i► v -�.a ;�, <br /> k <br /> i T t). <br /> Q <br /> C. <br /> Additional Descriptions for Materials Listed Above - K.Handiing Cosies for Wastes t_isted Above <br /> t <br /> r <br /> 1 pecial Handling Instructions and Additional Information — <br /> '` <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. f Date <br /> t Printed/Typed Name �ignature f Month Day Year <br /> FT 17.Transporter 1 Acknowledgement of Receipt of Materials — Date <br /> A ��- Month Da Year <br /> A Printed/Typed Name --TSignature y <br /> N <br /> P <br /> 18. Transporter 2 Acknowledgement of Receipt of Materials __ _ :i—Hdate <br /> i Printed/Typed Name Signature Month Day Year <br /> i19. Discrepancy Indication Space <br /> F <br /> 1A <br /> i G <br /> I i 20.Facility Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> l t Item 19. — _Date <br /> !f T <br /> T Printed/Typed Name Signature Month Day Year <br /> DHS 8022 A(11184) YELLOW: GENERATOR RETAINS 84 89641 <br /> (EPA 870022) <br />