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02/27/2004 FRI 13:09 FAX 13292689672
<br />Stele of California—Enviranmenial Protection Agency
<br />Form Appre ted OMS No. i'050-009 IExpires 9-30-99)
<br />Plcase print ar' type, For,n designed for use on elik f 12 -pitch rimr,
<br />9
<br />DK ENVIRONMENTAL
<br />See Instructions on back o e 6.
<br />[6002
<br />Deportment of Toxic Substances Control
<br />DO NOT WRITE BELOW THIS LINE. I"
<br />22A (1/99) Whitc: TSDP SENDS THIS COPY TO DTSC WITHIN 30 DAYS.
<br />DTSC BG
<br />FPA 870224 To: P.O. Box 3000, Sacramento, CA 95812
<br />UNIFORM HAZARDOUS1.
<br />Generolor's US EPA ID No. Manifest Document No.
<br />2. Page 1 InFarmollan In the shoded areas
<br />WASTE MANIFEST
<br />is not reg uired by Federal law.
<br />C A L 0 0 0 1 4 3 0 9 3 1 2 C> 6 1
<br />.fl
<br />3. General- s Name and Mailmq Addrxil
<br />A, Slate MoniFest Document Number
<br />Q8 REBUILDERS
<br />22821260
<br />2325 W. CHARTER WAY
<br />B. Slate Gencrator'b ID
<br />S�OCKTUI� CA 95206
<br />4. cncrator : one ( 2r1ov 7 7-0490
<br />�Nome
<br />5. Transport- 1 Company 6. US EPA ID Number
<br />C. Slate Transporkr`s ID R—rved,l
<br />ASBURY ENVIRONMENTAL SERVICES ICAU 10 12 18 12 17 17 10 IIJ6
<br />D. Transporter's Phone (800)974-4495
<br />7. Transport,, 2 C.mpony Nome 8. US EPA ID Nvmbar
<br />E. Slote Tronsporler s,14 [R—e ved.I
<br />F. Transport.,'_ Phone
<br />9. Designole�' Facility Nome and Site Address 10. US EPA ID Number
<br />'G. Stole Facility's ID
<br />D / K . ENVIRONMENTAL
<br />3650 EAST 2671-1 STREET
<br />H. Facility's Phone
<br />1 g Aye; c JA IT 10 18 10 10 13 13 16 ja ji
<br />(323)2 &-5056
<br />11. US DOT Crescription (including Proper Shipping Name, Hazard Class, and ID Number)
<br />^
<br />12, Conloraers
<br />13. To101
<br />Quantity
<br />14. Unit
<br />Wt/Vol
<br />I. Wast. Number
<br />No. I
<br />Typo
<br />a
<br />Stale
<br />RO HAZARDOUS WASTE SOLID, N-O.S. (CADMIUM, CHROMIUM, LEAD),
<br />p r
<br />0 e) 1 K
<br />7
<br />352
<br />EPA/pnc�r
<br />G
<br />9, NA3077, PGIII (D007, D008)
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<br />E
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<br />—
<br />RO HAZARDOUS�ASTE LIQUID, N.O.S. (CADMIUM,
<br />O 1 /-7
<br />9 d g35_
<br />�
<br />State
<br />' 131
<br />EPMAMA r
<br />R
<br />CHROMIUM,LEADNA3082, PG III(D006,0007,D008"4,
<br />`� (�
<br />A
<br />c _
<br />state
<br />0
<br />RO HAZARDOUS WASTE SOLID, N.0,S, (CADMIUM, CHROMIUM, LEAD),
<br />25
<br />EPA/Ot er
<br />R
<br />9, NA3077, pGlll (D007, Dooe)
<br />d.
<br />st
<br />19T AQrjrC!T1
<br />FPA/Of er
<br />J. Additional Dcscriplions For Materials Listed Above
<br />K. Handling Codes For Wasles
<br />Luted Above
<br />11A) 310116.27 ,1 3a
<br />a.
<br />11B)3t�0 X69
<br />�.d.
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<br />11C)X81-I& 510!/F evi
<br />15. i I , m nslructions and Addilionol Information
<br />USE PPE EMERGENCY CONTACT:CHEMTREC 1-800-4249300
<br />NAERG#: 11A)cA67*I1q 1 II6)£A6r:_171
<br />I I c)f-djayj_
<br />16. GENERATOR'S CERTIFICATION: I herby declare Ihoi Ike Contenle aF Ikis consignment are fully and accurately doscribod above by proper shipping name and are classified, packed,
<br />morked, �,nd labeled, and are in all respects in Proper condition For transport by highway according to applicable international and national government rogulotions,
<br />If I am a large quanliy generator, I cartiFy that I hove o program in ploce to reduce the volume and toxicity of waste ganeraNd to the degree I kove determined to be economically
<br />disposal Future threat to human health
<br />rcticable method of treatment. storage, or currently avoiloble to me MkrA minimizes the prcsent and
<br />procticob1, and Ihol I ho -e selected the ry
<br />I hove faith rho best ?hot Is
<br />and Ike environment; OR, if I am a small quantity genarat.rr, made a good effort to minimize my waste generation and scico wade management method
<br />available io m. and that I can afford.
<br />Printed/Typed Name
<br />Signalure , /
<br />nt` D �7Year
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<br />17. Trap2rter 1 Acknowledgement of Receipt of Malmials
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<br />SPrint
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<br />Ty�� Npm
<br />signature .. f
<br />Month Da Year
<br />y
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<br />18. Tramp—ler 2 Acknowled ee t of Recai t of Mo?eria15
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<br />Prinred/Tyrol N.mo
<br />Sign re
<br />Month Day Year
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<br />A
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<br />19. Dis cropor,, y Indicolon Spoc.
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<br />20. Facility O.nner or Operator Certification of receipt of hozordovs malerials covered b this manifest cpt as noted in Ilem 19.
<br />T
<br />Printed/Typed -4
<br />Signature
<br />Month Day Year
<br />Y
<br />Wel,,17 Z—
<br />DO NOT WRITE BELOW THIS LINE. I"
<br />22A (1/99) Whitc: TSDP SENDS THIS COPY TO DTSC WITHIN 30 DAYS.
<br />DTSC BG
<br />FPA 870224 To: P.O. Box 3000, Sacramento, CA 95812
<br />
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