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---Department of Health Services— . -- <br /> State of California—Health and Welfare Agency Toxic Substances Control Division <br /> Sacramento,California <br /> Please prim or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 11. Generator's US EPA ID No. Manifest 2. Pagg 1 Information in the shaded areas <br /> WASTE MANIFEST Document No. of is not required by Federal <br /> �� law. <br /> 3. Generator's Name and Mailing Address # �#tisier <br /> Tracy Printed Circuit Board c/o N. Sarnevesht <br /> 0 27902 S. MacArthur, Tracy. CA 95376 <br /> 4. Generator's Phone( 209 ) 836_4667 <br /> 5. Transporter 1 Company Name 6. US EPA ID Number S 10 <br /> Zero Waste tM ICAD071692016 aW,+nne. <br /> 7., Transporter 2 Company Name 8. US EPA ID Number pOttsf A ID <br /> erowasteS stems ICAD071692016 s e <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number AWe Facillty's 1D <br /> Solvent Service A 4 5 9 4 ,9 4 3 A 4 <br /> 1021 Serryessa Rd X&C1111ty's None <br /> - San Jose CA 95133 C A D 0 5 9 4 9 4 3 10 286-64 <br /> # <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) 12.Containers 13. 14 No. T Total Unit Waste f�1a,. <br /> Type Quantity t/vo <br /> 44 <br /> R <br /> C. <br /> }y <br /> •". <br /> d. <br /> 0) 0. /dd .til al Descri!ptlons for Mano odes for Wawefs Lfs l <br /> t rt`�ktD� f , w; c w I tits r <br /> Vitt <br /> N <br /> I1J <br /> LO 15. Special Handling Instructions and Additional Information + -- :- <br /> 00 16 protective clothing, gloves, goggles, respirator 1 <br /> Generator warrants that this shipment contnans no polychlorinated biphenyls <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. <br /> Date <br /> �t <br /> Printed/Typed Name S' ature — Month Day Year <br /> -(. <br /> r 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> A Printed/T=d Name Signature., ' Month Day Year <br /> 3 `•_ i. _ - <br /> P <br /> 18.Transporter 2 Acknowledgement of Receipt of Materials Date <br /> R Printed/Typed NameSig ture M n Day Y sr <br /> � <br /> .. <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 20.Facility eOwner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T 19Date <br /> Y <br /> Prated/Typed Name j Signature Month Day;��- <br /> Year <br /> �► GREEN: HAULER RETAINS <br /> DHS 8022 A(11184) 8489641 <br /> (EPA 8700-22) <br />