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Slate of California—Environmental Protection Agency <br /> Form Approved OMB Na.2050-0039(Expires 9 30-991 See Instructions on back 9e G. Department of Taut,Subtler."Coal,. <br /> Please print or type. Form designed for use as elite(12.Pik ewrim'. Sacmmenlc,California <br /> UNIFORM HAZARDOUS 1. Generatar's US EPA 10 No. Manifest Document No. 2. Page 7 Informationthe shaded areas <br /> is not requires d 6y federal law. <br /> WASTE MANIFEST ', c 11 'd of <br /> 5 a 4 <br /> 3. General.,',Name andMailing Address A. Stale Manifest Document Number �k n^ /�w <br /> GEb RAL MJL,S L L s X91 <br /> TTN: 6d)kE ERr�D`.;liHT;:Tt; B. Slot.Generarors ID <br /> $ CiY. 3a0i; LODT .�. _•c t .. 11 F. <br /> ^ 4. Generator's Phone( q r •y &F'IRRS99CS C01112ALT BOX 13 <br /> N S. Transporter I Company Name b. US EPA ID Number C. Slaw TraraporbYs ID[Reserved.] <br /> sm <br /> C? UN..7VkR :!SA -'_V. D. Transporle/s Phone <br /> o? 7. Transport,2 Company Name 8. US EPA M Number E. Stab TnsruPorm,'s ID[Reserved.] <br /> UNIV7-R !TSA INC.qzr <br /> t .1 f� - F. Tmnsporler's Phone <br /> � j CAR (. .. r; 4 7 �, s o 323-83?-734" <br /> 9. Designated Facility Nome and Site Address 10. US EPA ID Number G. State Facility',ID <br /> CO Q POLLUTION CCINTROL 1'NDOSTRIES <br /> 393 XENWEDT AVF,'N fG H. Facility',Ph.. <br /> O S^ ATCAGO, 1N4635,12 119-34?-3952 <br /> CC) T N D 0 0 0 5 ^ £ 21<11-2 <br /> I1. US DOT Descri tion(including Proper Shipping Nam.,Ho Class,and ID Number) 72. Containers 13. Total 14. Unit <br /> N U P li g P PPi^9 Na. T Quantity Wt/Vol -I. Waste Number <br /> Z o.NON-RCRA HAZA't2DOUS WASTE, SOLID (ABSORBENT AND slate <br /> F DEBRIS CONTAMTNA''.'ED ➢7= PRTROLELM HIrDROCARBONS) n "5 . <br /> 3 G T EPA/Oth., <br /> D N 0 <br /> wo N <br /> State <br /> E <br /> R tj�-ir �,. EPA/011ie <br /> v <br /> T c.NON-R.CRA: HAZARDCUS [iAs'IE, LIQUID State. <br /> o T p <br /> m O (63A TE OILS) / h 'A <br /> R �/ .EPA/011ier. <br /> D M <br /> W d. :$lab. <br /> Z <br /> W <br /> U EPA/Other <br /> w <br /> J. Additional Descriptions tar Materials Listed Above K. Handling Codes for wastes.Listed Above <br /> O Ila. 03080036NS ,rte ABSORBANT t: DEBRIS.-WT$ PETP.OLXUF4 R13560 b. <br /> N <br /> 11c. 0102O598LF WIXED OILSc, d,. <br /> a <br /> Z 15..V Special Handling Instructions and Addifi...I Information B^-AR APPROPP.IATE Pr<CTEC;TI\T GEA.T: 41faN N.71ADt <br /> 0 <br /> EMKIZGENCF CONTACT: CBMI'f7' EC: 1-800-429-9300, CALLER MUST IDENTIFY ONIV.71.R USA A, <br /> Z .SIiTPPE`r.. <br /> W PLAG'ARL'.S PROVIOaD BY CARRIER/SHIPPER 'a.S/NO DRIVER SIGNATIrRE <br /> r <br /> 16. GENERATOR'S CERTIFICATION: (hereby declare that the contents of this consignment are fully and accurately described abby proper shipping name and are classified,packed, <br /> U "marked,and labeled,and are in all respech in proper condition for transport by highway according to applicove able international and natioses government regulations. <br /> J IFI am a large quontiy generator, I certify that.have a proggram in place b reduce the volume and toxicity of waste generated to the degree I have determined to be ewnomicolly <br /> o. pr ticable and that I hhave selected the practicable method aF treatment,storage,or disposal currently available to me which minimises the present and future threat to human healtls <br /> and the environment,OR,if I a o mall quantity generator,I have made o goad faith effort to minimi..my w a generation and select the best waste.......rt method that is <br /> d' available to me oad that I can afford. <br /> O 1177 <br /> UIF <br /> (ygFt(I�t6_Te t'v" U' / Si to M nl <br /> Z <br /> W T 17. Transporter I Acknowledgement of Receipt of Materials <br /> wE Si e.-> ' Mo Da Ye <br /> B Printed/T o <br /> (! � Cir-,cert_, <br /> ts- B 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> O R Prinl.d/Typed Name $ignalore Month Day Year <br /> W E <br /> rn R <br /> U19. Discrepanq indication Space <br /> Z F <br /> A <br /> C <br /> L <br /> 1' <br /> 20. Facility Owner or OEenxsr Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Prinled/Typed Name SignaNre Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC$022A 11/991 Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> EPA 8700-22 To'. P.O. Box 400, Sacramento, CA 958 12 0,100 <br />