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State of California—Health and Welfare Agency Department of Health Services <br /> Toxic Substances Control Division <br /> 10- � Sacramento,California <br /> Please print or t;r.: (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. P e 1 Information in the shaded areas <br /> ocument No. is not required by Federal <br /> WASTE MANIFEST of law. <br /> 3. Generator's Name and Mailing Address G <br /> Tracy Printed Circuit Board Co. c/o N. Sarnevesht <br /> 4. VT902 �• MacArthur, Tracy. CA 95376 tie generator's 11) <br /> enerator s PhonMCI ) 836-4567 <br /> , <br /> 5. Transporter 1 Company Name 6. US EPA ID Number <br /> tatlep9rtises Phone <br /> 7. Transporter 2 Company Name 8. US AID Number t8 Ttenspo+ter' 10 <br /> F ratlsporter's Phone �•.w..wY. <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number tate Facility's 10 <br /> Solvent Service 4 9 4 <br /> 1021 Berryessa Rd a li o <br /> San Jose, CA 95133 C A D 0 5 9 4 9 4 3 10 <br /> 12.Containers 13. 14. I <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total Unit <br /> G _ <br /> No. Type uantity t/vo ' 1M1fasid <br /> Q <br /> N a. L J J ; <br /> E <br /> A b. <` <br /> C. <br /> i , <br /> OD <br /> Additiona for Materials t.isted Above K.Handting Codes for Wastes t.letpd AOil <br /> Mot <br /> a <br /> LO 15. Special Handling Instructions and Additional Information <br /> CD <br /> protectiv a clothing gloves , 909914s, respirator C <br /> Generator warrants that this shipment copains •xx 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 d t f) i Signature ! Month Day Year <br /> 107 117 186 <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials Date <br /> A Printed/Typed Name Signature / Month Day Year <br /> o 18. Transporter 2 Acknowledgement of Receipt of Materials Date <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> 20.F aecnlity,Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T 1 Date <br /> Y <br /> Z-A <br /> d/Typed Name Signature Month Day Year <br /> GREEN: HAULER RETAINS <br /> DHS 8022 A(11184) 8489641 <br /> (EPA 8700-22) <br />