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State oMa-1 I ia-Health and Welfare AgencyDepartment of Health Services~ Toxic Substances Control Division <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS �'- Generator's US EPA ID No. an est 2. Pa ormatlon 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 �,t a' ri c' Tielrb+ Nor <br /> Tracy Printed Circuit Board Co. c/o N. Sarneveshtt <br /> 27902 S. MacArthur. Tracy, CA 95376 State- Gewato(s ID _ <br /> 4. Generator's Phone( <br /> 209 ) 636-4867 <br /> 5. Transporter 1 Company Name 6. US EPA ID Number lata Tra"pv'et'& 1c r 4 <br /> Zero gaster Systems C A D 0 7 1 6 9 2 0 16 Ptx-u 04 <br /> i 7. Transporter 2 Company Name 8. US EPA ID Number to-to Trensp wf.efo ILS #" t <br /> Zero Waste Systems A D 0 7 1 6 9 2 0 6 'trah&porter's P'hona�.A16�3a � <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number tflt Fad ility�s ID <br /> Casmalia Resources 961 <br /> y I <br /> PO Box 5275 Facility's Phone <br /> J^ <br /> Santa Barbara, CA 93150 A D 0 2 0 7 4rr <br /> 12.Containers 13. 14. , +,: i. <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and/D Number) Total Unit <br /> No. Type Quantity tryo Waste No. <br /> IN <br /> d. .t <br /> i - K.H xS1z W- L ist <br /> CVV <br /> l.. <br /> i IUD <br /> t <br /> 1 .Special Handling Instructions andAdditional Information <br /> y w P' <br /> 00 <br /> Protective clothing, glavasI, popglIts, respirator <br /> Generator warrants that this shipment contains no polychlorinate-d biphWIS <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 ar n all respects in proper condition <br /> F for transport by highway according to applicable international and national gover tmental regulations. <br />!• � ,' Date <br /> Printed/Typed Name ` Signature Month Dey Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials . D <br /> t A Printed/Typed Name Signature ij' ` -- Month D Year <br /> r <br /> P <br /> 18.Transporter 2 Acknowledgement of Receipt of Materials % Date <br /> i A /Ty�SNam� �� Signa i Mon Y�a� <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 20.i aecnlity Ow or O erf t°� cation of receipt of hazardous materials covered by this manifest exce t as noted in <br /> 7 1 C/ /� Date <br /> Yrft6 r1nted/Typed aSignalaT9 Monte Day Year <br /> GREEN: HAULER RETAINS <br /> DHS 8022 A(11184) <br /> (EPA 8700.22) 1 /.� 84 89841 <br />