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State of California—Environmental Protection Agency
<br /> +formr Appr,jyed OMB Na.2050-0039(Expires 9-30-19) See Instructions on back of - 6. Department of Toxic Substances Control
<br /> Please print or type. Form designed for use on elite( 2-pitch)ty,. ..niter. Sacramento,California
<br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas
<br /> F:.. (('` ;1.t<•J;). is;(- 'j is not required by Federal law.
<br /> WASTE MANIFEST of
<br /> 3.,Generplor s Name an5l.ldai)jng f ddres _ A. State Manifest Document Number,TIN r
<br /> p t.s t (r4•r ir3I9 Ci95206 B. StateGener tat s ID
<br /> LO 4. Generator's Phone (=-'i-�` ) t '�' •-•" QA
<br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.)
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<br /> r' ` h `,+, t' D. Transporter's Phone
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<br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.]
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<br /> -4 J F. Transporter's Phone - -
<br /> U s9. tgn4lte�f F I tyt�' nd 4 dd ss st 10. US EPA ID Number G State Facility s 1
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<br /> ,D Z `:?o"��:I�x�+ML,,.f�T ! A 6 ;1626 Cs�t.7�..J0008451. J' H. Facility's P one
<br /> Q12. Containers 3. Total 14. Unit
<br /> U 11. US DOT Description(including Proper S ipping Name,Hazard Class,and ID Number) No. Type uantity Wt/vol I. Waste Number
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<br /> V EPA/Other
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<br /> nal•Dpjgrjj!tianTtrSf�Ayt rio[s Li"t� Above ;. t K. Handling Codes for Wastes Listed Above
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<br /> 16. GENERATOR'S CERTIFICATION. I here ddclare that the contents of this consignment are Fully and accurately described above by proper shipping name and are classified,packed,
<br /> Q marked,and labeled,and are in all res acts in proper condition F�r transport by highway according to applicable international and national government regulations.
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<br /> -J� If I am a large quontiy generator,I car ifs that I have a proggram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economical[
<br /> a practicable and that I have selected the racticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health
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<br /> and the environment;OR,if I am a sma I quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method thdPis
<br /> available to me and that I can afford.
<br /> Printed/Typed Npme Sig�ature i, r r r Month Day Year
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<br /> LU T 17. Transporter 1 Acknowledgement of Receipt of Materials
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<br /> A PnntedfT5'7d Name Signature � '" ,..,.�,r,y..,'�^ Month Day- �Yeaf.
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<br /> u_ 0 18. Transporter 2 Acknowledgement of Recei Dt of Materials
<br /> 0 R Printed/Typed Name Signature Month Day Year
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<br /> UF 19. DiscrepancyIndication Space ,
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<br /> 1 20. FacilityOwner or Operator Certification f receipt of hazardous materials covered by this manifest except as noted in Item 19.
<br /> T Printed/Typed Name I gnatu on Day Year
<br /> DO NOT-WRITE BELOW THIS LINE.
<br /> DTSC 8022A (1/99) Green: TRANSPORTER RETAINS
<br /> EPA 8700-22
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