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State of California—Environmental Protection Agency ` <br /> Form Aeproved OtOlt No-,2050-0039(Expires 9-30-99) See Instructionsy On back ofAaae 6. Department of Toxic Substances Control <br /> Please print or type'. form designed for use on elite _'(12-pits ite1A i Sacramento,California <br /> UNIFORM HAZARDOUS US EPA ID No. Manifest Document 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST 7nerator's <br /> L iOiOi0i1i2i4i3i3I2j3 6 O 4 1 5 all is not required by Federal law. <br /> 3 t mea A. State Manifest Document Number +1 <br /> O 130.5 E♦ VINE STREET, LODI, C A 95240 B. State Generator's ID <br /> p <br /> 411�1 . Generator's Phone(20lti9 ) )L,('' <br /> (V 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID:[Reserved.] <br /> CP h D. Transporter's Phone ENVIRONMENTAL SERVICES ; (91 6) 371-5747 <br /> ao 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's 1D[Reserved] <br /> I- Transporter',Phone <br /> Q - <br /> U 9. Fagli dye A 10. US EPA ID Number G. State Facility's ID <br /> Ll FG4tr�Jt1 ���+i�Xe�pa�ir � I�Y+r��i1��� W �y�g��� L+�,1^��T ,r^�A f�f�py�lr <br /> 7- 1630 WEST 17TH r"'TtAEET, ,IJt NG BEACH, CA 9081) H. Facility's Phone <br /> 0)0 (562) 432--5445 <br /> E0a 12. Containers 13. Total 14. Unit <br /> MU♦U 11. UtS�rDOT <br /> �D^+escription(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number <br /> y�I�= a.lftt r.?1E AEROSOLS, 2.1, U N195 State 31 <br /> �y <br /> 3 <br /> 3 G ERG 'OO #126 ,D F DO <br /> EPA/Other 01 <br /> o N TOXIC LIQUID, INORGANIC, N.O.S., 6.1, UN3287, III i State 141 <br /> N R (Didecyl--Di.�aethyl, Armniun Chloride) ERG 100 #151 01011 � � �00 E EPA/Other N/A <br /> A c State <br /> o T <br /> a0o O <br /> R EPA/Other <br /> w d. <br /> State <br /> Z <br /> w <br /> CJ EPA/Other <br /> w <br /> U) J. Ad�dition.)D+�es�c+r(i]p`tiyons for Materia Listed Above/�4 K. Handling Codes for Wastes Listed Above <br /> $qr <br /> O t, ry} y pyy } �y a_ b' <br /> UJI 11b. L 26994 [I a�,��L9Y 4 4 i,� ! �...f+t 00 � c d. , <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> F <br /> HANDLERS TO BE TRAINED AND USE C'A'F%. <br /> Z 241FR EMERGENCY CONTACT*- 916-311-5747 <br /> Uj <br /> 31 N. PACIFIC AVENUE, LODI, CA 95242 off' <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 /> U marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I am a large quantiy 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 /> 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 /> N 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 /> a' available to me and that I can afford. <br /> OPrin /Typ am Signa Ont Da ear <br /> u f, <br /> w T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> � (f,� <br /> � R <br /> Lu N Pri dYPed_N�m kl _Ts <br /> re O,Month. Day Year <br /> w S •RATA t/i W4 IIS [ Ke l � fC17 <br /> u_ 018. Transporter 2 Acknowled ament of Recei t o Materials <br /> 0 T Printed/Typed Name Signature Month Day Year <br /> LU E <br /> Q R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> - A <br /> C <br /> L <br /> I 20. Facili Owner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19. <br /> T Printed/Typed NAme Signature Month Day Yepr <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />