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..t <br />and Welfare Agency OmpartmenI of Health services <br />CIS No. 205 --OON (Exp"s 9-3091) Toxki` rs COW911,111110101" <br />or type. (Form designed for use on elite (i typewriter). <br />NIFORM RDOU8 1. 4iernerator's us EPA w nb: Manifest <br />2. age 1 Information In the <br />ASTE MANIFEST Document No. <br />of is not required by Fr <br />and Mailing Address <br />12Q <br />% <br />w <br />fin T a fly Nam 0. U8 EPA V Number <br />Qt 111tos, Transparwq 0, <br />L.°TrsnspgM any Name 0. US EPA ID Numberr-7M <br />, (gate frIt �. <br />17,1 MCI <br />a <br />• ' Name sed SitsIOUdress 10. A tt1" f <br />so is <br />4 t, i r <br />aims <br />%43 <br />12. Costs <br />re t3. Total 14. <br />11. US DOT Description (Including Proper Shipping Name; Hazard Class, and 10 Number) <br />Quantity Unit <br />No. <br />Type Wt /V 1 `' e <br />a. <br />r< a PV= <br />" <br />E <br />Is. <br />T. <br />e4...: <br />.- <br />t*: <br />F� a. Hassfor <br />, <br />77 - <br />1 % Instructions and Additional information <br />BATOR'SCERTIFICATION: I hereby declare that the contents of this consignment are fully end accurately described above by proper shipping <br />and are olasaffled, `pooked, marked. and labeled. and are In all respects In proper condition for transport by highway according to applicable laternatletwolut <br />astionsill government regulations. <br />a <br />N 1 am a lags quantty generator, 1 certify that I have a program In place to reduce the volume and toxicity of waste generated to the degree I have defetatin edi <br />to be that i have the <br />aawtoMrnlcaNy practicable and selected practicable method of treatment, storage, or disposal currently available to me whkdh minimtzaa <br />pretest 40 fuhae threat to human health and the environment; OR, If I am a small quantity generator, 1 have made a good faith effort to mkdmize my waetle <br />�ar"d <br />select the best waste management method that is available to mea that i can afford. <br />1 . Transporter t AoMm Materials 00,001 <br />� <br />A <br />Name tmcam try <br />t <br />Wall <br />2 ,AftiffivIedgemeat of Reoelpf of Materials <br />P+Inbud/Typed Name Signature Afonth Day, Year <br />E <br />VC ,olsomparmy buscawn Space <br />F <br />A <br />C <br />L <br />I <br />9a Owner or Operator Certification of reoeipt of hazardous materials covered by this manifest except as noted In Item 19. <br />T <br />Y <br />/Typed Name <br />Signature ` <br />DNS SM A (1 ISM Do Not Write low This line <br />EPA 2 Blas: GENERATOR SENDS THIS COPY TO DONS WITHIN V DA, , <br />Previous sdtbns we obsolete. Tot P.O. Box 400, Sacramento, CA 95812. <br />,t <br />