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i <br /> �— ,®r:dies:5afwele°�-u,`1aI1.. :.�--._-, ...�... - —/^_{f{_'���......._._.__�.� ----- - <br /> r11 Sc -s7 �7 l/�eoartment o/Health Services <br /> Callfarn N--r�•altn ana v4elrsre Agency L /� J J (�'1�TJo c Suostances Control Division <br /> � I Sacramento,Gllfornla <br /> PkSS ! -f <br /> wse onnt or type. (Form designed for use on hte 112-o1r er t <br /> Operator 3 0. enirest age lmormeuon in the snaaed areas <br /> �j UNIFORM HAZARDOUS � Document No. is not required by Federal <br /> Of law. <br /> WASTE M A N I F EST A.State Menrfem Document Number <br /> 3 Name and Mailing <br /> re�, 84168159 <br /> 13.State Generator's 1 <br /> 4 e t U I Numoer lata Transporter <br /> 1 <br /> i I o ransoo�r 1 Company Name d. <br /> i <br /> ransporter s31- <br /> tate Transport I <br /> j I rsnsoorter Con, y Name US EPA 10 NUmoer <br /> ransporter's no <br /> _ I Number tate sulrry's 10 <br /> esignated eCiiitY Name a Jit• r � 11 <br /> / /II <br /> 96 -lam� I,ty74 one I�'O <br /> Qooa <br /> 771 37dz <br /> 12.Contaln 13. 1 � <br /> i 1 1.US DOT Dexr on(including Proper Shipping Nam . Hatard Cast and ID Number Total Unit Waste No. <br /> No. T e Cuanti <br /> 0 <br /> j � .. Jai <br /> IE r G <br /> le , <br /> A <br /> T <br /> 0 <br /> I ^ <br /> i <br /> C. <br /> Q <br /> r �-P ,•' 1 K.Handling Codes for wastes Luted <br /> - <br /> �► 'L? k�� <br /> I haling nsvuctlons and Addrtlonsl In ormsuon poo <br /> CERTIFICATION:I hereby tleclare the a contents o s consignment ars fully and accurst described <br /> spore by proper shipping name and are classified,packed,marked,and la l•d.and are in all respects in proper condition for <br /> transport by highway according to applicable international and national governmental regulations. <br /> Date <br /> Pnnted/TypeO <br /> Name Si urs M h Da a rJ <br /> T 17. Transporter 1 Acxnovvi"ement of Receipt of Materials Date <br /> ♦ f�Ttnt•d/7 N� $ net • Month Oa <br /> M 119. jr <br /> o 18. Transporter 2 Acknowledgement or Receipt of aterials / Date <br /> T Prtmed/Typed Name Signature Month Day Year <br /> r <br /> 19. Otscrepancy Indication Space <br /> A <br /> c <br /> I <br /> 1. <br /> I 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> T ham 19. <br /> y oe <br /> rent yped Name ignatUr• Month Day Yeer <br /> White: TSCF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> aMs 8022 A (7MA) Tn Znno SdCrcImenko, CA 95812 <br />