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rr_�. _..a -...... -- -116.• 1V) nifnhm h.nnvuifnr m <br />Form Approved. OMB No. 2050-0039 <br />r uabu <br />V,M.l VI qpv. ml Vliil <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2, Page 1 of <br />3. Emergency Response Phone <br />4. ManifestTrackingNumber 5 9 JJK <br />WASTE MANIFEST <br />C A L O O O 1 9 O O 8 O <br />1 <br />5. Generator's Name and Mailing Address Att: TED NICHOLUS Generator's Site Address (if different than mailing address) <br />THREE WAY CHEVROLET <br />CALIFORNIA AVE <br />BAKERSFIELD CA <br />Generator's Phone: <br />6. Transporter 1 Compan Name U.S. EPA ID Number <br />MP Environmental Services C A T 0 0 0 6 2 4 2 4 7 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8; Designated Facility Name and Site Address U.S. EPA ID Number <br />Forward Landfill <br />South Austin Road <br />Manteca CA <br />Facility's Phone: 9m Q"-A7M <br />9a. <br />9b. U.S. DOT Description (ncluding Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />. and Packing Group ('d any)) <br />Quantity <br />WtNol. <br />1' NA2212r Asbestos <br />151 <br />a <br />9. PGIII <br />CM <br />30 <br />Y <br />Z <br />2. <br />w <br />3. <br />4. <br />14. S ial Handifn Instructions and Additional Information <br />�)FRIABL-E ASBESTOS, PROFILE # 9232. ER 171 PROPER PPE VMEN HANDLING. <br />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 classified, packaged, <br />marked and labeledlplacarded, 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 Pdmary <br />Exporter, I cartify that the contents of this consignment conform to the terms of the attached EPAAcimowtedgment of Consent <br />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. <br />Month Day Year <br />GenerstorslOfferor's Printed/ryped Name SignatureVV <br />16. Intemationa Shipments <br />❑ Import to U.S. ❑ Export from U.S. rt of entry/exit <br />' <br />- <br />Transporter signature (for exports only): Date leaving U.S.: <br />= <br />Li <br />17. TransporterAcknowledgment of Receipt of Materials <br />LirTrma!ngsp-orte�r2 <br />Print ame Sfgnetu Month Day Year <br />loq <br />Name Sig re Month Day Year <br />18. Discrepancy ' <br />18a. Discreppnoy Iniicpflon anti ue s _j� „ 2�tlat Rejection - ❑ ull Rejection , <br />c �rIC�l) <br />nifest Reference Number. <br />18b. Alternate hollity (or nerator) U.S. EPA ID Number <br />J <br />V <br />Facility's Phone: <br />1 tic. Signatureof Alternate Facility (or Generator) - . - - Mqnth - Day Year -.' <br />Z <br />19. Hazardous Wa to Rqppd Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />®1 <br />2. 3. <br />r <br />4. <br />20. Designated Facility Owne or Operator. Ce ' tion of receipt of hazard ateriais covered by the manifest except ndeq in Item <br />8a <br />1 <br />Printed(Typed Name Signature <br />6 07 <br />Month ,Ray ear <br />EPA Form 8700-22 (Rev. 3-05) PRIM s editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRE ) <br />10640.1661 <br />