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n rn..--- -4-4 .., -- /C...... a...„......a tom. j- nn olitn Itch! 112 ! Wnauttitar 1 co . U r n.. L54,- 10-3- 7- Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. 10640.1662 DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) �... y.,...� ......._..� UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number 0 03208361 WASTE MANIFEST C A L 0 0 0 1 9 0 0 6 0 1 �- 5. Generator's Name and Mailing Address Aft- TED NICHOLUS Generator's Site Address (if different than mailing address) THREE WAY CHEVROLET CALIFORNIA AVE BMERSFIELD CA 93M4 - Generalor's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number MP Environmental Services C A T 0 0 0 6 2 4 2 4 7 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Forward Landfill South Austin Road Manteca CA Facilitys Phone: 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (d any)) Quantity Wt.Nol. t NA2212, Asbestos �L 5 9, PGIII Cm Y z 2. w 0 3, 4. 14. Special Handling Instructions and Additional Information I)FRIABLE ASBESTOS, PRORLE 0 9232. ER 171 WEAR PROMR PK V11111HENI-IMMING. 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classhled, packaged, marked and labeled/placarded, and are in all respects In proper condition for transport according to applicable International and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcimovAedgment of Consent. I certify that the waste minimization statement Identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generetor's/Offeror's Printe0 ped Name Signature Month Day Year Ste. L-sqS";A, 16. Intemationa Shipments Import to U.S. El Export from U.S. Port of entrylexlt: Transporter signature (for exports only): Data leaving U.S.: 17. TranspolorAcknovAedgme oelptofMaterials V. Slgn Month Day Year Trans 1 Printed/Typ.90 N 1*1 Transp6rter 2 Pdnted/ryped N me Vature Month Day Year 18. Discrepancy Dls ncy Ndicabon Space u Residu� j P'rO Re an 1 Full ReJ on ,pG/• ]�It fern u er. 18b. Alternate Faclllly (or Generator) U.S. EPA ID Number J V -4 ' Facility's Phone: W 167. Signature ofAltemate Facility (or Generator) _ _ - _ Month Day Year N 19. Hazardous Wa Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ®1 2 3. 4. 20. Designated FacilityOwner or Ope r. Certification of receiOdtizardous materials covered by the maridest except as noted in Ite 8a Printed/Typed Name j �/� - Signature I / J ) ' o a 1c EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. 10640.1662 DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)