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41— <br />DO <br />DO NOT <br />DTSC 8022A (1/99) <br />EPA 8700-22 <br />RIFE BELi9,W THIS LINE. <br />tYellow-:\ TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-of-state, <br />` produce completed copy of this copy and send to DTSC within 30 days.) <br />v <br />State of California—Eovironmentol Protection Agency <br />Form. Approved OMB No. 2050-0039tExpires 9.30-99) See` Instructions on back o ge 6. Department of Toxic Substances Control <br />Please <br />print <br />o type. Form designed=jor use on elite (12 -pitch iter. Sacramento, California <br />UNIFORM HAZARDOUS <br />, erator's°US EPA ID No. Manifest Document No. <br />1. G ' <br />of on in the shaded area` <br />fAllof <br />is not required by Federal laud•.' <br />WASTE MANIFEST � 6 .. <br />. ,ta ,C� . r jryl19 17 1411 tt <br />'' 0 <br />._ 5 <br />/.z 0 o `;Q % - <br />3. Generator's Name and Moiling Address " <br />State Manifest Document <br />Number <br />BUa_{.-,1. .i f0N NOIUIJER1 Sk,'+ A <br />L <br />140 E. C1fL�v'�%rIE i�fi1V`I?, SAN 33FERNARDINO CA f)Z4 $ <br />B. State Generator's ID <br />koA. <br />Generator's P one ( t t, - .. <br />ft/ <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C: State.-Transpo er' ID Reserve .} <br />h <br />c0 <br />D. Transporter's Phone <br />�_ <br />^ <br />2sn ny �' ; t S E A m r 1. <br />u <br />E. State Tnihsporter's'1b R <br />�-, <br />V <br />'F. Transporter's Phone <br />9 Designated Facility Name and Site Address 10. US EPA ID Number <br />G. Stafie cility's ID <br />Z <br />CROSBY kNI) OVt•:R�£i�� <br />c <br />o <br />1630 w; ; 37TH STS f <br />H. Fatffi s hone <br />P <br />Q <br />V <br />CA 1A 1h <br />C <br />11US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />1 C`onfainers <br />13. Total <br />Quantity <br />4. Unit <br />Wt/Vol <br />I Waste,Number <br />No. <br />Type <br />_ <br />a' Asx ra 1`cs �' r�t',ds tmf,C3.wJ+rc /c9 ✓ x'nw'.vr 3"%"`e°e' d; rcd as t .da <br />F .•_-'" <br />S <br />3 <br />G <br />(. i <br />Cs L'% { <br />y <br />e!3 a'� rt <br />P <br />EFA/CltheF <br />E <br />N <br />b. <br />State <br />E.. <br />R <br />EPA/Other <br />A <br />0 <br />® <br />C. <br />FERtiRTs CED WASTE RUSE cEIV <br />� TplENT OR ®• HANDLED <br />state <br />_ <br />R <br />Trr�IEpVV H TO �.ByTFrEpEpARTAgVERT N.t <br />Sr <br />pFC , <br />SI! SEQ <br />EPA/Other' <br />w <br />f- <br />d. AND VATION AND GENCy W ACC <br />PERtT,IS STATE REGU RECOVERY <br />CCFPT <br />NC7D <br />BSTAN <br />RDANCE W <br />�r1k <br />-4 OLJ <br />URi�IJ. <br />rOGET}dE; <br />State <br />" <br />V <br />ACCOippy Y T1{E <br />WAS Y &AO'LR <br />TE <br />N76 TSOC <br />��I7H <br />VISIONS p; <br />Ef+A/Other.' <br />LU <br />AND qty <br />OF <br />IC B <br />L4 1 <br />ZJ.' <br />Additional Descriptions for Materrols 1 istedAbove <br />a$ki9Nrg� r Wastes <br />'1i <br />`e5{ Lrwd2\ t 3i <br />tld $`` <br />b <br />aq. <br />Uj <br />c. <br />[d <br />Z <br />o <br />15. Special Handling Instructions and Additional Information <br />W <br />F -IR ()YEACT CW1/MARK0 gREEXAO 909-625-6645 <br />H <br />,+77 tZ� '70,1 /)d ,I p i,. ci: OC 9-7ry, 'Q <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 />marked,'and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />-J+ <br />If I am a large quantiy generator, I certify that I have a prooggram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br />practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health <br />93e <br />and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br />O <br />available to me and that I can afford. <br />>_ <br />Printed/Tyj/ped Name tilt/ , fir"! J¢ *�. yrr <br />Signature <br />Month Day Year <br />Z <br />a 7e:s�,p <br />w <br />R <br />4.e'C!/�9 a r3 t/' y a"?� g'% <br />v <br />17. Transpoiter 1 Acknowledgement of Receipt of Materials <br />w <br />p <br />Printed/T//aped Name <br />Signature- <br />Month Day Year <br />11 <br />° <br />U_18. <br />'fyFh <br />Transporter 2 Ac nowled ement of Receipt of Materials <br />TPrinted/Typed <br />Name <br />Signature <br />Month Day Year <br />W <br />vs <br />E <br />R <br />V <br />19. Discrepancy Indication Spate <br />Z <br />— <br />F <br />A <br />C <br />L <br />1 <br />20. Facility Owner or Operator Certific receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />T <br />Printed/Typed Namej <br />S' uure, <br />ont Day Year,! <br />41— <br />DO <br />DO NOT <br />DTSC 8022A (1/99) <br />EPA 8700-22 <br />RIFE BELi9,W THIS LINE. <br />tYellow-:\ TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-of-state, <br />` produce completed copy of this copy and send to DTSC within 30 days.) <br />v <br />