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Cr•, <br />State of California—Environmental Protection Agency , <br />Fogm 6pprpyy)y{ OMB No. 2050-0039 (Expires 9.30-99) <br />Please R? t, or type: Form designed For use on,elite' f 12-pitchJ ty er. <br />0 <br />in <br />n <br />N <br />LO <br />00 <br />W <br />'! <br />U <br />" O <br />O <br />J <br />U <br />G <br />2 <br />C <br />a <br />2 <br />LL <br />a <br />L <br />V <br />a <br />C <br />L <br />U <br />L <br />a <br />U <br />`u <br />C <br />L <br />See. Instructions on back of 6. Department of Toxic.5 6bstdnces Control <br />.Sacramento, California <br />UNIFORM HAZARDOUS 1. No. Manifest Document No. 2. Page 1' Information in the shaded areas <br />is not required by Federal law. <br />:, WAS k, . MANIFEST�" of <br />.. <br />3. Generator's Name and Mailing Address A. State,Monifest Document. Number <br />SSC -San Ramon - <br />R.O. Box 5095. Roam 3000. San Ramon, CA 945€33 B. State Generator's ID <br />4. Generator's Phone ( 925 901-5584 Attn: Cesar Cruz <br />5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID [Reserved.]. <br />A D Trans orter s Phone <br />ARS. Inc. ,,. �'°►^ ., ` _ 1 . :: g, : J p <br />7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID (Reserved.] <br />F. Transporter's Phone <br />9. Designate facility Mame and Site Address 4,g mb r 6 G. State Facility's ID <br />NWS Hey Road Lapdfill I I I I I <br />6425 Way Road H. Facility's Phone <br />Vacaville CA 9568-7 (7 7) 6i8-6692 <br />'*,. 11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) 12• Contoiners 13. Total 14. Unit <br />..�,, No. Type Quantity Wt/vol 1. Waste Number <br />a. State W.# <br />R-0. Asbestos, 9. NA2212. PGiII tERG#171) 151 <br />G bay 010EPA/Other. Issir; <br />N <br />E b - - f State- . <br />j <br />R EPA/Other <br />T C. State <br />O <br />R--F.?A/Other <br />d, State <br />EPA/Other <br />J. Additional DescripPions for Materials Listed Above " K. Handling Codes for Wastes Listed. Above <br />11a. Pipe Insalation a- es,, <br />d. <br />15. Special Handling Instructions and Additional Information <br />Emergency Response Guide In Vehicle, Wear OSHA Approved Protective Clothing And Respiratory Protection WMn t•lartdmg. <br />IN CASE OF EMEERGE 14CY CONTACT: Chemtre+c:-PCCN at 1-800-424-9300 <br />Site pick up address: Stockton. 907 W Lincoln Road Stockton CA 95207 Job # 8 7 6 2 <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 I am a large quantity generator, I certify that I hove a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economicallyy <br />practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and Future threat to human heolth <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/Typo <br />1flf4%'t0 3�-tiJ�_"I� ft •tom°t ,s rfignature Month <br />Day Year <br />f/ 119 d21 <br />C O <br />T 17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A Pr* ted/Typed Name J Sig r Month Day Year <br />R!' <br />Sd <br />P Al <br />B 18,4ronsp-orterl Acknowledgement of Itecei t of Matenals <br />T r' ed/Typed N me/�f / Signature Month Day Year <br />19. Discrepancy Indication Space <br />FA <br />C <br />I <br />I 20. a '0 ' _ or e'' r 'it tion of recei t of hazardous materials covered b this manifest exce tas noted in Item 19. <br />T Printed/Typed Name Signature Month Day Year <br />Y <br />DO NOT WRITE BEL`OW THIS LINE-.-'- <br />2004`-t-�ii`r 1 Am TOP,Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />22A (1/99) C (Generators who submit hazardous waste for transport out-of-state, <br />DTSC 80 <br />EPA 87022A produce completed copy of this copy and send to DTSC within 30 days.) <br />Generator's US EPA ID <br />DO NOT WRITE BEL`OW THIS LINE-.-'- <br />2004`-t-�ii`r 1 Am TOP,Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />22A (1/99) C (Generators who submit hazardous waste for transport out-of-state, <br />DTSC 80 <br />EPA 87022A produce completed copy of this copy and send to DTSC within 30 days.) <br />