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Gloria—Health and Welfare Agency r .,r Department of Health Services fori+oAp$rb�e0 OMb,No`2680-0039.(Expirea 9- Toxic Substances Division Please print or type. (Form designed for use on a itch typewriter). Sacramento,California UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest 2. Page I Information in the shaded areas Document No. WASTE MANIFEST C A 11 9 i! 1 3 7 5 1 5 7 of snot required by Federal law. 3.-Generator's Name and Mailing Address A. State Manifest Document Number t,��eark Sierra d �. Job #534 90231215— 8o0 W, Churn Street, Stodctonf CA. 95203 e. State Generator's ID 4. Generator's Phone( 209) 466-5251 H JA ti 10 1316 - jO 1313111912 O 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's d) n ARgy INC. IC ilk ID 19 18 11 16 13 14 18 19 12 D. Transparter's Phone 91 N W 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID o F. Transporters Phone m 9. Designated Facility Name and Site Address 10. US EPA ID Number G. S ' acility's ID An�ereon Solid Wash lS18I1131g18191512 4 ,� aclli s Phone v 18703 Cambridge Road, Anderson 96007 Lr) a ,) alc � c s 916»347-3236 12. Containers 13. Total 14- 1. O 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. IL No. Type Wt/Vol State J M Asbestos Eailding Material 151 N = G AQ Waste hazardous ElUbetance )) / J yt;. EPA/Other 0 3 "E b. State m q EPA/Other W T NAD NQ a [R C. State - g EPA/Other m W "d _ State EPA/Other W W J. Additional Descriptions for Materiels Listed Above K. HandliU Teas for Wastes Listed Above Z a.. b. y'. Asbsstm containix)g building mterials SMTP Dal *1 W. Z 0. 15. Special Handling Instructions and Additional Information Z .W DO NOT MW BWS 0R CAUSE MT. AVOID ➢NL'i[aat"EM D=- BM SEPA$ATELY AND COVER WITH REFUSE. J J V. 18, GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name -1 and are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and Wnational government regulations. If I em a large quantity generator,I certify that I have s program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me whichminimizes the present and future threat to human health and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste Vgeneration and select the best waste management method that is available to me and that 1 can afford ZMonth Day. Year w - Printed/Typed Name Signature t nom. W C t,, LL ,1 r f T 17. Transporter 1 Acknowledgement of Receipt of Materials j' W R Z A Prints ped Name Signature Month. Day Year f )a N e, � r ' P 18. Tren porter 2 Acknowledgermlintlof Receipt of Materiels R Print yped Name/ Signature Month .D9ye E z_ 19. Discrepancy Indiciftion Space F Q. &44 S';�x.'40 A C i5 i,y. _�) Cnli frP,J FJ. I :_ (trtJ�iil (<q�1 I L I 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. TSignature Month Day Year y Printed/Typed Name IIC:J • DHS 8022 A(1/88) Do Not Write Below This Line EPA 8700-22 - (Rev.9-88)Previous editions are obsolete. ' Yellow:TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DA