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,e of Ca',fornia—Health and Welfare Agency Department of Health Services <br /> Toxic Substances Control Division <br /> 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 /> D c t of is not required by Federal <br /> WASTE MANIFEST CAD 9 8 1 1 7 0 3 43 `�''�' �� law. <br /> 3. Generator's Name and Mailing Address A.State Manifest Document Number; <br /> Tracy Printed Circuit Board Co. C/o N. Sarnevesht 85024881 <br /> F .' <br /> 27902 S. MacArthur, Tracy, CA 95376 B.State Generator's ID <br /> 4. Generator's Phone( 209 ) 836-4567 03 c <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C.State Transporter's ID <br /> Zero Waste Systems IC A D 0 7 1 6 9 2 0 1 6 D.Transporter's Phone 415-893-8257 <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E.State Transporter's ID <br /> F.Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G.State Facility's ID - <br /> Solvent Service <br /> 1021 Berryessa Rd H.Facility's Phone <br /> San Jose, CA 95133 C ,\ D 0 5 9 4 9 4 3 10 408-286-6446 <br /> 11.US DOT Description(Including Proper 12.Containers of 14. i <br /> p ( g p Aping Name, Hazard Class,and ID Number) Total Unit <br /> No. Type Quantity ANtfvoi Waste No. <br /> N C1 0 <br /> T b Ll gS(E IQ U () of0 .uaS Lam '- 7 pa <br /> cos t �-cet �� if <br /> c. ;.t ps ,0 c,t Uv 14�C-S <br /> d. us A&re <br /> v u --1q <br /> ;Z Q. - <br /> Ad`Id'itio2al Descriptions for M t�erials L ted Above K.Handling Codes.for Wastes Listed Above <br /> ;6-4: �� 13 40 Wk 1l.� t� ocp�l t <br /> �Su �1�tfG o <br /> �1JR�kkz w <br /> n 15. Special Handling Instructions and Additional Information <br /> O rotectiv e clothing <br /> p g gloves , goggl4s , respirator <br /> e612 ik Y7— <br /> Generator <br /> iGenerator warrants that this shipment conains oxm no polychlorinated biphenyls i <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 a!I respects in proper condition <br /> for transport by highway according to applicable international and national govern ntal regul ions. <br /> Date <br /> Prjr IVintedlT ed N m Signature Month Day Year <br /> a 47 17 86 <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials Date <br /> APrinted/Typed Name Signat re Month Day Year <br /> S `S cl o <br /> P <br /> 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> R Date <br /> T Printed/Typed Name Signature Month Day Year <br /> E i <br /> R <br /> 19. Discrepancy Indication Space ` <br /> F <br /> A 4 <br /> c <br /> i <br /> L 20.Facilityy Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in <br /> I Item 19. <br /> T <br /> Date <br /> T Pr ted/Typed Name Signa ur Month Day Year <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> 8022 A(11/84) To: P.O. Box 3000, Sccromento CA 95811 2 ea 89641 <br /> 1 8700-22) <br />