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L N .HAZARDOUS WASTE MAi _, IST <br /> Please print or type (Form designed for use on elite If pitch)typewriter) <br /> 1.Generators US Manifest 2.Page 1 <br /> NOWHAZARDOUS Document No- <br /> WASTE MANIFEST 8 z n of a <br /> 3.Generators Name and Mailing Address 14A FT._ ATUAI®TTf Tf'ifF'I ;ft <br /> ARM #760 20 BOX 9087 <br /> 225 S. CKE-ROKEE IBIS RGELE S, CA rtoo J.9 <br /> 1A)D I, Ch P AVI. S131'M <br /> 4.Generators Phone( (925)946-1-085 <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.State Transporters ID <br /> 5 i �: �.Transporter 1 Phone 925 63-1-€i85 Q <br /> 7-Transporter 2 Company Name 8. US EPA ID Number C.State Transporters ID <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number E.State Facility's ID <br /> 19U- LARDIFILL <br /> 9999 SOUTH AUSTIN ROAD F.Facility's Phone <br /> si c CA 95336 <br /> ` 12009 982--4298 <br /> 11.WASTE DESCRIPTION 12. Containers 13. 14. <br /> Total Unit <br /> No. Type Quantity Wt.Nol. <br /> a. VON MAN SOIL, (Pf: 2317) <br /> C) >yA. �} 1 <br /> G b <br /> E <br /> N <br /> E <br /> R <br /> A <br /> T <br /> O <br /> d. <br /> R <br /> W <br /> H <br /> G.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> .J_j-, <br /> cc <br /> Q <br /> 15.Special Handling Instructions and Additional Information <br /> s,arr gr_nca Uantacir (925)634--Wit il DI.LI.blartb <br /> Z <br /> 16,GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are fully and accurately desFnbed and are in all respects <br /> in proper condition for transport.The materials described on this manifest are not subject to federal kzardous waste regulations. <br /> ,J ,( Date <br /> Sigria' I r-9a Yew. <br /> PrintedlTyped Name <br /> T nsporter 1 Acknowledgement of Receipt of Materials <br /> — Date <br /> R I'�'t \ Sicnatureth Dq Year <br /> A Pr t diTyped Name - (/\ t//1 <br /> S r I, . <br /> 0 18.Transporter 2 Acknowledgement of Receipt of Matenals Date <br /> R Printed/Typed Name Signature Month Day Year <br /> E <br /> R 19.Discrepancy Indication Space <br /> F <br /> A / 1 <br /> C20.Faoliry Owner or Operator,Certification of receipt of the waste matenals covered by this manifest.except as noted in item 19. /l <br /> Date <br /> i <br /> T ��d,-Fy�peq Signaure � onfh Day Year <br /> - -. <br /> J <br /> ®wrrto o.wec.u[c>.rrc- <br /> C F 14 r..AKA ASM®(800)621 sttlOB w.rw.IebeMnasler.cpn us..c so�erw», �sOv rrxt <br />