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Stara of California—Environmental Protection Agency <br />f,�rn App?oved OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back of - e 6. Department of Toxic Substances Control <br />Please print or type. Form designed for use on elite (12 -pitch) h er. Sacramento, California <br />C <br />v; <br />C11 <br />rt; <br />CF <br />C <br />C <br />)CF <br />i_ <br />_Q <br />�z <br />°C <br />rC <br />J` <br />Z <br />EEF <br />3 <br />c� <br />C <br />a <br />a <br />C, <br />c <br />C <br />a <br />ILL <br />t- <br />2 <br />LL <br />L <br />u <br />v <br />C <br />0 <br />U <br />0 <br />C <br />U <br />t <br />C <br />DO NOT WRt'FE BEL THIS LINE/ <br />1\ White: <br />To: <br />TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />P.O. Box 3000, Sacramento, CA 95812 <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />is not required by Federal law. <br />WASTE MANIFEST <br />CAL 0 0 0 0 7 8 518111 <br />of 1 <br />Genera r ame and Mailing Address <br />A: Stale Mariifgs) en! Number +� ^ <br />7. <br />; <br />oys-s <br />! 1/v{ <br />1624 Army ct. <br />B. State Generator's ID <br />Stockton, ca 95206 <br />A. Generator's Phone ( 209 ) 465-4942 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C: State Transporter's ID [Reserved.] <br />*V%CAj'7 <br />T TS EN vt 20 ii -4 / t /�/ C-G L <br />D, Transporters Phone �a L9 _ ZcF4 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />7. <br />E State Transporter',s ID [Reserved.] <br />0 i�s0 fjb4: ED A (t <br />F, Transporter's Phone <br />s t d c' ' and Site Address 10. US EPA ID Number <br />G,- State Facility's ID <br />1630 west 17th St. <br />H. Facility's Phone- <br />LONG BEACH, CA 90813 1 CAD 012181 4 0 9 0 11 9 <br />(562)432-5445 <br />1 1 . US DOT Description (including Proper Shipping Name, Hozard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />I, : Waste Number <br />No. <br />Type <br />a. luii—Rcrct Hazardous WasteState <br />' 3 5! <br />Filters) ERG#171 <br />EPA/OthI101i@ �n <br />G <br />0 0 1 <br />D M <br />0 9 2 0 0 <br />p <br />E <br />b. <br />State, <br />N <br />E <br />EPA/Other <br />R <br />A <br />State <br />T <br />c <br />O <br />EPA/Other <br />R <br />d <br />State <br />EPA/Other <br />/ktf (t& -I Dss�rgq�s-tjr,Materials Listed Above ? <br />K, Handling Codes For Wastes Listed Above ; <br />� <br />o <br />d: <br />ng]Stg+�fetp1Aitio7g��orm (Fremouw Enviornmental) <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed, <br />for by highway according to applicable international and national government regulations. <br />marked, and labeled, and are in all respects in proper condition transport <br />If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br />disposal to me which minimizes the and future threat to human health <br />practicable and that I have selected the practicable method of treatment, storage, or currently available present <br />OR, if I am a small I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br />I <br />and the environment; quantity generator, <br />available to me and that I can afford. <br />Printed/Typed Name - <br />Signature <br />Month Day Year <br />© <br />O <br />t T <br />I <br />1 Transporter f Ackn wled ement of Receipt of Materials <br />R <br />Pria /Typed N e <br />Signature <br />Month Day Year <br />R <br />1 S <br />o <br />P <br />0 <br />18. T.Lansporter 2 Acknowled ement of Recei t of Materials <br />i R <br />T <br />Prin d p ame Signatur o Day Year <br />t E <br />t R <br />19 is e n n im on ace <br />F <br />A <br />C <br />I <br />L <br />Facili Owner or O erator Certification of recei t of hazardous materials cove this manife t exce t oted in Item 19. <br />T <br />inted/Typed Name <br />F <br />Si at <br />¢-month Day Year <br />DO NOT WRt'FE BEL THIS LINE/ <br />1\ White: <br />To: <br />TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />P.O. Box 3000, Sacramento, CA 95812 <br />