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L <br />01/28/2010 12:44 FAX <br />• <br />Pe368 Print or Nw. (Form dealaned fir urs an elks (12 -pitch) "ariniter.) <br />Z014/019 <br />�F_ C��wSt a_ 2047 <br />Form Approved. OMB No. 2p50.DG39 <br />EPA Form 87Po-22(Rev.3.05) Previous edUnsamobsolem. __AfSJPNAfE6FACILITYTODE"NA N STATE (IF REQUIRED) <br />10276.0974 <br />UNIFORM HAZANOOu3 1' Vvnurumrr ID Numhv <br />R Pape 1 ol <br />J. Eneg011ry R6aperee Plme <br />A ManNrds Tn rip N..Mr <br />000237731 JJ K <br />WASTE MANIFEST CAL000258912 <br />1 <br />8DO-747 <br />S. Garemlars Name and Meiling Address commiri 51b Adeea (d ddt M men mellhe eddms) <br />Tower Mart Store 0184 <br />7210 Roseville Rd <br />Sacramento, CA 95842 <br />Gelmmtbra Prwo. <br />6. Tran�ner pray arra ..FpA1D Numbar <br />UNIVERSAL ENVIROMENTAL, INC- CADN63652272 <br />7. Mn5Xrbr 2 Company Name U. S. I:PAIDN, <br />_ <br />I l VOV�Mt i�4aQ I i 1L C (kf2 000 19a 41 <br />B. sled FMelry Name end 61re Addnae U.S. EPAID Number <br />ROSBYAND OVERTON CA0028409019 <br />- 1830 W,17TH ST . <br />LONG BEACH, CA 90813 <br />Fedi Phan- 582`492'5445 <br />Be. <br />9bU.S. DOT pperbtlon(h4Wing Proper 9blppirG Nemo, NareN mac. ID Nu�aa <br />10. Cunleirem <br />ll.Tda <br />12. Udt <br />13. Abam Codes <br />No. <br />Typo <br />HM <br />M Gmup (d any)) <br />qua" <br />WWd- <br />X <br />lammab(e we.t.i..(grid, N.O.S., (water WlgasoAne), 3, UN1993, PG11 <br />Dill <br />G <br />343 <br />0001 <br />DO18 <br />ao <br />so <br />w <br />2. NorrRCRA Hazardous Waste P,P.E Debris WliMace Gasollne) <br />DNI <br />1�O <br />P <br />352 <br />�Q <br />3. <br />4. <br />ItSpodiAlHandIUV lnehutlbre a Addlnovl Inlwmednn <br />9b1) Pro}Ile 084780 UE Job 04164 <br />ebz Romen64787 <br />• I Wear Roper P.P.E. When Handling <br />15. GENERATOR9IOFFEROWSCEIrnFICAt1ON: Iheeby darlen tlrrt tln mnmrNdma mndpnmemWfaF/and safrsehdGaAlad abdw oY eie DmON sneW9name.abntlaT9apd, parkegad, <br />marked and mbaladpm®med, and min 80 mapecta M prupruondthat for traMpeR BD:O'Dlry m dpplldda IrSxnaDDRalano naJonal D'A'emmantd rpgrAatlone. W egnR ehlpmabl and I em me Pdmery <br />Erporen I crdry Nal dw wnuma of INS NhalpNmanl ODddma b We arms of the aUCW EPAAcKVW*VWl N CdnSW <br />I cu* Net ha "a% me1M'vatlon HJUmant Ideneaed In 40 FPR 26M(a) (W I am a large quenaygenenow) m (b) IN am a small qumM penarelor) le true. <br />WrvOAamea Prinmarryped Name Sgnaft. Da res <br />611 log <br />1dl ria <br />❑imp eIb U.S. ❑ExpoRfivn U.S. Pod deMyleo[ <br />Tfare Ngraan IV e=aonh): Data k.*t; U.S.: <br />17.TrareprtrAdrerA dWDalpla AUaadala <br />Tmnspnlerl pad Name SlpreWm _ Montl, fD1a Y <br />CZ <br />Ot <br />ma po oma Slgrewre MWI1 WY Tbu <br />7- 019 <br />1B. ' <br />1 <br />18a. Dla� Ind"UM Spatia ❑ Ouv* ❑Type ❑ I.eldee ❑ Pa tld Ral0.ton ❑ Fu0 Rejeelon <br />Martrad RWrand medr. <br />18b.ARrremFadliry (r Oenerlmr) U.S. EPAID Humber <br />SY' <br />FadltWa Phots. <br />11, 1,no" clPfamae Fadlly lef GfefAtCv) Mad, Day Y. <br />- <br />1S. Heradoae WIMP RdDOn MANIC"M M*Cd [odea he., cedes M hazard. ana M uaaemnt locoed, and nWrlp "All) <br />17" f/ J. <br />a. <br />20. DWgNil10 Fadllly O'.Nlror Openmr. (`smf' uaeon d natlpl d furaMwt maNAW w.Ertd q' Ofl mtlM10Y esppt as Mad IN Imm t8a _ _ <br />Prim ad Nemo rebus MDne1 Ory YW <br />Ill <br />EPA Form 87Po-22(Rev.3.05) Previous edUnsamobsolem. __AfSJPNAfE6FACILITYTODE"NA N STATE (IF REQUIRED) <br />10276.0974 <br />