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State of Cali enc ia—Health and Welfare A Department of Health Services <br /> O y Toxic Substances Control Division <br /> o . . in Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST Document No. of iswnot required by Federal <br /> 3. Generator's Name and Mailing Address <br /> Tracy Printed Circuit Board c/o K. Srnevesht <br /> gIP0� S. lay,S�rthur, Tracy, CA 95376 <br /> 4. er or s P o ) <br /> 209 836-5-9741 <br /> 5. Transporter 1 Company Name 6. US EPA ID Number <br /> T <br /> 7. Transporter 2 Company Name 8. US AID Number <br /> U <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number Stat;ll '9 ' <br /> Micro Metallics <br /> 1695 So. First Street sell a ne <br /> San Jose, CA 95112 CAD069124717 <br /> 12.Containers 13. 14. I <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total unit Waste No. <br /> No. Type Quantity t/vo <br /> G <br /> N a. waste, cyanide solution, NOS, Poison S, UN1935 <br /> E t i <br /> A <br /> T b. : <br /> R C. <br /> i, A. <br /> i <br /> stir,. <br /> d. <br /> CD <br /> J.= ' dditionat Descriptions for <br /> f <br /> ' t <br /> - <br /> Ln 15. Special Handling Instructions and Additional Infomaatlon <br /> 00 <br /> ,protective clothing, gloves, oggles, respirator <br /> Generator warrants that this shipment contains 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 /> Printed/Typed Name „ Signature �-�'� Month Day Year <br /> 0 .. RV *y - r/r <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials Date <br /> A Printed/Typed Name Signature _ y Month Day Year <br /> N / <br /> s <br /> o 18. Transporter 2 Acknowledgement of Receipt of Materials Date <br /> T PrintedlTyped Name Sig ature Month Day Year <br /> E <br /> R — \^ <br /> 19. Discrepancylndicati grace <br /> -- <br /> F <br /> A <br /> C <br /> � 20. Facility Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> I Item 19. Date <br /> TMonth Day Year <br /> Y ,PrintedlTyped Name Signature <br /> GREEN: HAULER RETAINS <br /> DHS 8022 A(11/84) 8489641 <br /> (EPA 8700-22) <br />