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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-1039(Expires 9-30-99) See Instructions on back ofI* G. Department of Toxic Substances Control <br /> Please print or type. Foran designed for use on.efite(12-pill,A,. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generators US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> is not required 6y Federal law. <br /> WASTE MANIFEST A L 90101 1 2 4 5 0 0 0 018 of 1 <br /> 3. Generorors Namapnd Mailing Address B + R AUTO SALES REPAIR <br /> 6733 Main St . On E-Ill V <br /> San Jose CA 95128 i <br /> in 4. Generators Phone ( l s <br /> K Y <br /> N 5. Transporter I Compc-nYT45me 6. US EPA ID Number a e <br /> Goldun Bear Transportatio C A 1 7 9 3 4 6 r ' <br /> �. 7. Transporter 2 Company Name 8. US EPA ID Number <br /> 9. Designated Facility Name and Site Address 10• US EPA ID Number ?r <br /> a Kalifornia Environmental p �' <br /> 1 1 1213 Septic Tank Wy <br /> 0 Oakland , CA 94612ICI AP 12 191 qO 171 (10 1311 --� <br /> Total 14 T <br /> Containers 13. o <br /> 11- US DOT Description{including Proper Shipping Name,Hazard Class,and ID Number) 12. Unit <br /> No. T Quantity Wt/Vol Jt < <br /> a. <br /> F _ Hazardous waste , solid , n .o . s . ( F005 ) <br /> 9 , NA3077 , III 1 a IM15 0 Px <br /> E ' <br /> o N b. ,� <br /> Goo E <br /> v R <br /> v A <br /> o T <br /> co 0 •. <br /> I.- d. <br /> Z <br /> U <br /> LU <br /> ;: Iml�t',Cad@.s.3f ., <br /> rsr"` 1 ? a <br /> V). 4sryYv '-x �'P ti <br /> su _ fi � .;.IiA V- <br /> F., <br /> Q �x-- ';" -'�j •' q�'' { ` sf+A s,, sd ts"r '„n. ;., •2v '� �`;: t' "'w <br /> ti�-.� <br /> Z i 5- Special Handling Instructions and Additional Information <br /> Q <br /> Z <br /> w <br /> x <br /> t- <br /> 16. GENERATOR'S CERTIFICATION; I hereby declare that the contents of this wnsjgnm mt are fully and accurately described above by proper ship ing Rama and are classified,packed, <br /> O marked,and labeled,and are in all respects in proper condition For transport kry highwory according to applicable international and nationa�government regulations. <br /> —" If I am a large quantity generator,I certiFy that I have a p rom in place to reduce the volume and toxicity of waste generated to&degree I have determined to be economically <br /> sz pracfjcoble and that I have selected the practicable method of treatment,storage,or disposal currently available tome which minimizes the present and future threat to human health <br /> and the environment;OR,if I am o 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 /> 0 <br /> Pri /Typed Name Sig Month Day Year <br /> z 0 JZ D 11 012- <br /> 17. Trans rter 1 Acknowledgement of Receipt of Materials <br /> W Ii Prin yped Nome Signature Month Day Year <br /> / D <br /> U.1 818. Transporter 2 Acknowled ement Recei t of Materials <br /> 0 T Printed/Typed Name , Signature Month pay Year <br /> E <br /> R <br /> <i <br /> 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> E <br /> 20. Facility Owner or Operator Certifjtafion of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Printed/Typed Name Signature Month Day Year <br /> i. <br /> DO LVOT Wkitt ML604 CHIS`IINE;,, <br /> DTSC 8022A 11/991 Blue, GENERATOR SENDS"THIS COPY TO DTSC'WI7HIN.16:D'AYS. ' <br /> EFA 8700-22 To: P.O..Bnx-400; Sacramento, CA . .95al 2-0400 . <br />