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Stale of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30.99) See Instructions on bac' . Page 6. Department of Toxic Substances <br /> Please print or type. Form designed for use on elite(12-F ypewriter Sacramento,California <br /> UNIFORM HAZARDOUS �1AjL1bjDjbjZjU,j3iSj6, 9 ! <br /> . Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> is not required b Federal law. <br /> WASTE MANIFEST 0 5 4 2 oft I q y <br /> 3. Generator's Name and Mailing Address 'D;p,)Ti AA[s/7��ij /. /AIS y -- A. State Manifest Document Number <br /> 344.145 5..r�C Te(ls \!V1/4/�T U. 2359054 <br /> 1�►�L� �A �S 37� B. State Generator's ID <br /> LO I 4. Generator's Phone (Z09 )6�ea y(a-2— <br /> n <br /> <N 5. Transporter I Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.) <br /> h <br /> oASBURY ENVIRONMENTAL SERVICES i C A D 0 2 8, 2 7 7 0 3 6 D. Transporter's Phone (800)9744495 <br /> `00 7. Transporter 2 Company Name 8 US EPA ID Number 1 E..Slate Transporter's ID.[Reserved I <br /> lV <br /> �Q F. Transporter's Phone - <br /> Lnu 9.67kncI p�441Jjtx�{4�tp��Sjte Address 10 US EPA ID Number G. State Facility's ID <br /> ®Q / f� tNUlt(V(VM N I,qL <br /> 3650 EAST 26TH STREET <br /> CAT 0 8. 0 0 3 3 6 8 .1rFili y's Phone <br /> 0LOS ANGELES CA 90023 3)268.5056 <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> /�y No. Type Quantity WI/Vol I. Waste Number <br /> _Ho. yA,^+, �_.. _.� iC�o oZ a00 I State <br /> r <br /> 3 G IJP LIR2A{1LLiOPOL 154X.D C a IL'(60L.103') ° D � EPA/Other <br /> oO N b. 1 Stateco <br /> coo E <br /> R EPA/Other <br /> v A <br /> o T a <br /> State <br /> OD O <br /> R EPA/Other <br /> i <br /> w d. State <br /> Z <br /> w <br /> V EPA/Other <br /> LU <br /> N J. `Additional Descriptions for Materials Listed Above �( / F I K. Handling Codes for Wastes Listed A6ove <br /> �J 'S o. b. <br /> r � , <br /> LU <br /> °C c. d <br /> J <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> USE PPE <br /> EMERGENCY CONTACT:CHEMTREC 1-800-424-9300 <br /> Z NAERG#:Lu <br /> T <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and occurately described above by proper shipping name and are classified,packed, <br /> Q marked,and labeled,and are in all respects in proper condition for transport by hignwcy according to applicable irternational and nolional government regulations. <br /> u <br /> If I am a large quantity generator,I certify that t have a program in place to reduce the volume and cox city of waste generated to the degree I have determined to be economical) <br /> a practicable and that I hove selected the Practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human healt! <br /> N 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 i <br /> a available to me and that I can afford. <br /> 0 <br /> } # Printed/Typed Name <� Signature Month Day <br /> U (!// Y/r/'/�T/� U� <br /> Z <br /> LU T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> LU <br /> w A Printed T;ped Ngme Signature Month Day Y( <br /> N I+i� <br /> :Es <br /> Lu P <br /> w 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 R P,inted/Typed Name Signature Monih Day Ye <br /> T <br /> w E <br /> N R <br /> VF 19 Discrepancy Indication Space <br /> Z A <br /> I � <br /> L <br /> I 20. FacilityOwner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19. <br /> T Printed/Type ame Signature Month Dcy Ye <br /> Y fill (16,16) <br /> DO NOT WRITE BELOW THIS LINE. <br />