|
State of California—Environmental Protection Agency
<br />Form Approved OMB No. 2050-0039 )Expires 9-30-99) See Instructions on back of nage 6. Department of Toxic Substances Control
<br />Please print or type. Form des;gned for use on elite (12 -pitch) t iter. Sacramento, California
<br />0
<br />LO
<br />LO
<br />t\
<br />CV
<br />V)
<br />O
<br />0
<br />ao
<br />yJ �
<br />i i Z
<br />'v o
<br />w
<br />N
<br />N
<br />_Z
<br />2
<br />W
<br />LU
<br />t—
<br />Z
<br />LLJV
<br />LU
<br />N
<br />Z
<br />O
<br />LO
<br />W
<br />a
<br />Z
<br />O
<br />a
<br />Z
<br />ILL!
<br />Q
<br />V
<br />N
<br />O
<br />LU
<br />h
<br />Q
<br />V
<br />Z
<br />DO NOT WRITE BELOW THIS LINE.
<br />DTSC 0 (1/99)
<br />EPA 87700-0-22 Yellow: GENERATOR RETAINS
<br />terator's US EPA ID No. Manifest Document 1
<br />2. Page I
<br />Information in the shaded areas
<br />UNIFORM HAZARDOUS
<br />is not required by Federal law.
<br />WASTE MANIFEST
<br />° 4
<br />i f, I , If, 1� i hI 1, U �� i
<br />3. Generator's Name and Mailing Address
<br />A. State Manifest Document Number w �i
<br />03 REBUILDLR
<br />L
<br />?325 W. C HARI FR WAY
<br />B. State Generator's ID
<br />4"W�rs'Phane I (::A 2(W)
<br />A67-010,
<br />5. Transporter 1 Company Name 6. US EPA ID Number
<br />C. State Transporter's ID [Reserved.]
<br />A'AlORY E NVIRONMENTAI `;I=-RVI(J'S [� I 1 I „
<br />D. Transporter's Phone
<br />(8W)974-446
<br />7. Transporter 2 Company Name 8. Us EPA ID Number
<br />E. State Transporter's ID [Reserved.]
<br />F. Transporter's Phone
<br />9. Designated Facility Name and Site Address 10. US EPA ID Number
<br />G. State Facility's ID
<br />01 K ENVIRONMENT»
<br />H. Facility's Phone
<br />3650 I.ASI 26CH �-IITFI •• r
<br />I US s •S f t' Ii_i 16 •rj ,i ' 13 k, 1H i,2.
<br />50',,6
<br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number)
<br />12. Containers
<br />13. Total
<br />Quantity
<br />14. Unit
<br />Wt/Vol
<br />I. Waste Number
<br />No.
<br />Type
<br />a.
<br />State
<br />F?O HA7ARDO(IS WAS•I E SO I.If), N O t, ECl+[)Pviti.lP/I, i;Hr?C�M(UM, I.r A()s,
<br />352
<br />EPA/Other
<br />G
<br />4, ,NA3077• 1011i (DO07; I-008)
<br />.i Q
<br />N
<br />1
<br />`
<br />y
<br />E
<br />N
<br />b.
<br />State
<br />E
<br />Its? HAZARD(AJS WAST F, I IGUID, NO S. (GADMIUM
<br />EPA/other
<br />R
<br />r;u,clrlE,AIt1P�d,I.E:f�E1, NA30$2, I'CS IH(t10fi,E?tJ$I,E;(lOti�1•i•
<br />C)
<br />I
<br />(� `
<br />�
<br />T
<br />C.
<br />stare
<br />p
<br />RO HAZARDOUS WASTE pCX.IU, N 0,S. (GADMIUM, C.HR(MdIUM, LEAD),
<br />R
<br />9, NA30•r'7, PCaf ii f ROUT, D(1[li3)
<br />{ I
<br />1 ��
<br />I.)
<br />EPA Ot er
<br />d.
<br />St
<br />'—t4tN"P _'' c'i i'" '.I'�I""I"I't 'EE- ;''P'1- •.c�'�r( e%%+i Ekf ..� - --- -..,Y_....
<br />..,...
<br />_..._..._...
<br />..r
<br />EPA/ er
<br />J. Additional Descriptions for Materials Listed Above
<br />K. Handling Codes for Wastes
<br />Listed Above
<br />11A) 3.19116•-27 • Y :�=C)
<br />a.
<br />b.
<br />'1113) 330321-60 X_055
<br />1161, 310116-27 C W
<br />C.
<br />d.
<br />15 c in nstructions and Additional Information
<br />USE PPE E=ME RGENCY C ONTAC;T .CHEMERE(, 1800-424-9300
<br />NAF.R(##
<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 />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 1 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 economically
<br />future human health
<br />practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and threat to
<br />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 />available to me and that I can afford.
<br />Printed/Typed Name �/ t/ ;�
<br />Signature �i _. -
<br />Pont -)iDai)Lj (Year),
<br />y
<br />TR
<br />17. Transporter I Acknowledgement of Receipt of Materials -
<br />A
<br />PrinteaYTyped Nam q
<br />Signature
<br />Month Day Yeor
<br />S
<br />P
<br />0
<br />18. Transporter 2 Acknowledgement of Receipt of Materials
<br />R
<br />T
<br />Printed/Typed Name
<br />Signature
<br />Month Day Year
<br />E
<br />R
<br />19. Discrepancy Indication Space
<br />F
<br />A
<br />C
<br />L
<br />1
<br />20. FacilityOwner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19.
<br />T
<br />Printed/Typed Name
<br />Signature
<br />Month Day Year
<br />Y
<br />DO NOT WRITE BELOW THIS LINE.
<br />DTSC 0 (1/99)
<br />EPA 87700-0-22 Yellow: GENERATOR RETAINS
<br />
|