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State of California—Environmental Protection Agency j1 /� �j <br /> Form Approved OMB No.2050-0039(Expires 930-99) i [ 5 LOOlee Instructions on ba 4 page 6. Department of Toxic Substances <br /> Please print or type. Form designed for use on elite f 12-p. Typewriter. Sacramento,California <br /> I. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST v U 0 0 0 0 1 of 1 <br /> 3. Generator's Nome and Mailing Address Oak Park Gas b Convenient 2250428 <br /> A. State Manifest Document Number <br /> 3212 N. California St. <br /> � B. State Generator's ID <br /> sLn 4. Generator's Phone f ) Stockton, CA 95204 <br /> t\ 289 941 2691 <br /> N 5. Transporter 1 Company Nome 5. US EPA ID Number C. State Transporter's ID[Reserved.] , <br /> LO <br /> o Belshire Environmental Svs. A D 9 5 8 4 6 8 1 D. Transporter's Phone 949-450-1010 <br /> 0 <br /> 00 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved] <br /> �Q F. Transporter's Phone <br /> C"IV 9. fgteb}ilr &dress 10. US EPA ID Number G. State Facility's ID <br /> 0z �u1770+44 ++�+EEST,�VF+I�R++ST"STREET H. Faci iCPO 13 s Pha QL.P 1031 <br /> �X AZUSA,CA 91702 C A 8 0 3 0 2 9 0 3 626-334-5117 <br /> f.VQ 12. Containers 13. Total 14. Unit <br /> 11. US DOT Description{including Proper Shipping Nome,Hazard Class,and ID Number) No Type Quantity Wt/Vol I. Waste Number <br /> NV <br /> Hazardous Vaste Solid, n.o.s. State 352 <br /> 3 9 NA3677 P.G. III EPA/Other <br /> G <br /> (0018, Benzene) D H 0 P 001] <br /> o N b. <br /> State <br /> ao <br /> co E EPA/Other <br /> N <br /> R <br /> A c State <br /> 6 T <br /> aao O EPA/Other <br /> R <br /> State <br /> LU d. <br /> t- <br /> w EPA/Other <br /> V <br /> LU <br /> N J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> O o. ( b. <br /> I <br /> Ji <br /> Z 15. Special Handling Instructions and Additional Inform tion <br /> g -n HOUR EMERGENCY PHONE: Site: Oak Park Gas b Convenie. <br /> Z YEAR ALL APPROPRIATE 949-450-1010 (H-F Sam-5pm) 3212 N. California St. <br /> Z <br /> w PROTECTIVE CLOTHING 949-753-5826 (24-hours) Stockton, CA 95204 <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 reclassified,packed, <br /> Q marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> V <br /> J <br /> � If I am o 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 economics <br /> n practicable and that I nave selected the trackable method of treatment,storage,or disposal currently available to me which minimizes rhe present and future threat to human hec. <br /> V) and the environment;OR, if I am a small quantity generator, I hc,re made a good faith effort to minimize my waste gen and-select the best waste management method that <br /> Oavailable to me and that I can cfford. <br /> r Pri t d Qyped N me ^ ;:qnZore Morth Do <br /> Z `moi <br /> w T 17. Transporter 1 c nowle emerl f cei of Materials <br /> � R Si <br /> ,nylon toY <br /> w p Printed d �� '�✓\ <br /> � N V <br /> w S <br /> P <br /> U- D 18. Transporter 2 Ack w!ed ement of Receipt of Mot ials <br /> 0 T Pri ed/Type Name Signature Month Day <br /> V) E -,qe D <br /> Q R <br /> V 19. Discrepancy In n Space <br /> Z F <br /> A <br /> C <br /> L <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials JOPIA Y is rn es!exce t as noted in Item 19. <br /> SI o e Month Day <br /> T <br /> ^;T Y Lev <br /> �- G <br /> I <br /> DO NOT WRITE BELOW THIS LINE. <br />