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Stare of Cali ornra--Environitlensol Protacltun Auoncy <br /> Form Approvbd 0150 No 2050-WJ9{Expires Q JO 94) See Instructions on bock of page 6 DepaAmc t of Toxic Substances Corvro <br /> Please pnnFor type Form fjavpgtd for use on elda(]?p+rch)ypewnSoc'—wo California <br /> rer <br /> "' 1 GLnerafar s US EPA ID No Mandesi Document No 2 Page 1 lnformaihon in the shaded areas <br /> UNIFORM HAZARDOUS IS not requiri.d by Federal law <br /> WASTE MANIFEST F _f7 C1 1P (3 17P 1�+ �6 7 7 of 1 <br /> 3 Generator's Nome and Mailing Address A State Manifoq Document Number <br /> W.W. MILES 92867597 -- <br /> P. O. PDX 128e, LOS r;L fOS, CA 4024 fs State Generotor s ID <br /> � 4 GenarosorlPhone (}15A 31-18--67C)Eco <br /> r5 5 Tronsporsar I Company Name b US EPA ID Number C State Tronsporter's ID <br /> W NOR GAL— Q i L CAD 93 - L 17 `5 D Transporter s Phone <br /> (,ar)y <br /> -+ 7 Transporter 2 Company Noma 8 US EPA ID Number E State Tronsporter's ID <br /> a <br /> U F Transporler's Phone <br /> Q 9 Designated Facility Noma and Site Address 10 US EPA ID Number G State�acihfy's!D _ <br /> U O ENVIFQPUR WEST COPPORATION IPQ 3 <br /> 13331 NORTH HWY.. 33 H Facility's Pha <br /> Ln O�s <br /> J PATTt=RSQN CA X5363 C F- '3 �'3 1 G 7 -S f/ <br /> V <br />[� I1 US DOT Description[including Proper Shipping Name Hazard Class and ID Number) 12 Containers 13 Total 14 Unit <br /> z No Type Quantity Wt/Vol 1 Waste Number <br /> Oar NOA—RGRA HAZARDOUS WASTE L I QUID statF2rsT— <br /> a;T7 G (WATER ec SLUDGE ) JI �.1 T T l-1 EPA/Other <br /> E <br /> m N b Stale <br /> co E <br /> vR EPA/Other <br /> A <br /> T c State <br /> co <br /> - - <br /> R EPA Other <br /> LU <br /> r d <br /> � Seara <br /> LU <br /> EPA/01h,r <br /> 14 1.fusted'� avq`,a'+t 4e a)I' ��' '+1i1 v. 1r ct ''+i i K Handling Codes For Wastes Listed Above4 <br /> 7s� 31'J�4 r i,st {`rstti",". f V 'i I <br /> 0. W f�yteia'11 , sr'i°r� r i�'tc R. �. 4 s. q<<:r� w c r r b a < <br /> ' T pT,TQI1 WASUj <br /> TE spy^F'�� "� �'�' .� �a�r , <br /> � <br /> 1'e' r '■p ", F(4 <t+.klS d71`�r _'L*�wri14¢ •e 't�as.i y,W s �( , r ��,n Fye-. 'z4 c :}i . S.� da. .. ; <br /> Z <br /> 0 15 Special Handling Instructions andwAddit+onol Information <br /> 4 APPROPRIATE PROTECTIVE CLOTHING JOB SITE. <br /> Z "EMERGENCY IEONTACT: (2109 )667-6692" 1145 W. CHARTEr- WAY <br /> LAJ <br /> SEE E.R.G. 31 STQC L TON, Cis 520,6 <br /> r <br /> 16 GENERATOR S CERTIFICATION I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified <br /> J <br /> packed marked and labeled and are in all respects in proper condition for transport b highway according to applicable federal state and international laws <br /> Q p P P P P Y 9 Y 9 PP <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 <br /> economically practicable and that I have selected the practicable method of treatment storage ar disposal currently available to me which minimizes the present and future <br /> a threat to human heallh and she environments OR if I am a small quantity generator I have made a good faith effort to minimize my waste generation and select the best <br /> rr1 <br /> waste mans oment method ut Is available to me and that I can afford <br /> 0 Printed/Typed Name Signos a Month Day�r <br /> r �L LLQ '�/LG!��r Ltd d 0 <br /> ZT 17 Transporter 1 Acknowledgement of Recast of Materials 7 <br /> LN A Punted/Typed Name Signature ons^� _pay I rye{ar,,.1 <br /> LU 5 <br /> P <br /> 0 18 Tran: orter 2 Acknowled ement of Receipt 0l Materials <br /> w 7 Printed/Typed Nama notura Month Day Year <br /> LLA 19 Discrepancy lndication SPoce <br /> v7 j <br /> 4 F <br /> A <br /> C <br /> 1 <br /> 1 20 F-cility Owner or Operator Certificanon of ace i t of hazardous materials corered thro rnonifcsr rrr�,t ns not d in 'tem 19 <br /> T Printed/Typed Name /l r Signature / } Month any -�)Icor� i <br /> Y ' lipr N i ,'�� t, iii'/ sem^tLf�'leA— 10 0 1 i <br /> DO NOT l R! E BELOW THIS LINE <br /> OTSC $022A (7/92) <br /> EPA 8700--22 <br />