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4 <br />Stare of Agagry I <br />Form App&d OAS No. ]050-00] (Expires 9-0694) s � '-^ <br />Pl.. prim or type. Farm designed far user on e&. (12giMr) t ro winsar. <br />UNIFORM HAZARDOUS=,' <br />: us EPA IDWASTE.MANIFEST F) <br />3. Generator's Nome and Moiling Address AYIAUN() I <br />o : - 2245 W. CHARIER WAY <br />to <br />an SlUCKION, CA 95206 <br />r A. Generator's Phone ( ) ( 209) 466-8604. <br />m 5. Transporter'I Conspmy Name 6. US EPA ID Numb. <br />O <br />to <br />SHOP HAZARDS SULUI IONS C A <br />7. Tramponter 2 Company Norm S. US EPA ID Numb. <br />Q <br />U <br />-a 9. Designated Facility Name and site Address 10. US EPA ID Number <br />)Z STATEWIDE ENVIRONA9ENTAL <br />)0 12618 MAIN STREET <br />-< LOS ANGELES, CA 90061 CAD 0 0 0 <br />,)L) <br />T Z <br />fl—US DOT Description (mdudmg Proper Shipping Nome, Hazard Oan, and ID Number) <br />)� RO, WASTE OXIDIZING SUBSTANCES, SOLID, <br />)3 G N.O.S.,'5.1, UN1479, 11 (DO01) <br />of E <br />o b, <br />m E R0, WASTE PESTICIDES, SOLID, TOXIC, N.O.S. <br />R (ENDOSULFAN), 6.1, UN2588, II (P050) <br />A <br />o T -- <br />m 0 <br />R <br />z <br />W <br />Z d <br />W <br />u <br />W <br />OdtsaranaTs'tssicd".",Abmsel <br />CCtt''s4 _ } <br />_ 3 <br />a <br />1 N <br />See Instructions on back of pogo 6. <br />No. Manifest Document No. <br />S '> 113 <br />16 11 til 81 81 C . <br />Coliforrvo ' <br />Mfonmafiaa in the <br />shaded areas <br />b net inquired by Federal law. <br />12. Comainers ' 13: Total 11. Unit <br />No. <br />T Quantity <br />) of 7 <br />Department of Toxic subaom. Control <br />Sacramento, <br />Insirvctions and -Addd"anal Inrvrmaro <br />15. 5 p carol Handling <br />O �4 HOUR E3dERGENCY RESPONSE NlN>BER 1 (889)-399-4357 <br />77A. PROFILE #gFllnic.39-A ' <br />Z 716.. PROFILE # �(o(p7�_ � Z = • <br />W Bio%o � ; , <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this comignment are fully and accurately described aborc by proper shipping none and are clbnified; <br />Qparked, marked, and labeled, and are in all respects m proper condition for transport by highway according ro applicable imemationol and national goverrcnrst_ rcgvla8om. <br />V- <br />H I am a large quantity generator, I certify that I here, a pogrom in place ro rcdvice the vokme and roziciy, of waste generated to the degree I hone determined ro be <br />ecommucally proc6cable and that I hwe selected the practicable method of vevtmem, storage, or disposal cvrrcnlhj ovailabk b me which minimises. the prose. and future _ <br />d threat ro human health and the enviro.nem; OR, 'rf I am a ..It quomitv ale I ode a f e waste generation and elect the best <br />to _ .. .. . ilpveril un$.°�rT°�', offal <br />.. �(t9`nFl...lal °af.do, <br />Wt/Vol <br />0 0 1 <br />D M <br />/ P <br />P�- <br />i <br />1 '}d <br />I'FiiIT'J111'Iiel <br />QPrinmd/Typed Name Signatut�' , MoNh'Your' . <br />V T 17. Trvns er 1 Acknowledgement of Remi of Materials <br />- <br />Z F by <br />U' rAi Prmted�Typed Ngme,�er-er �E/FG S�graNrc / j,/ Aletlh . Day /tar <br />K z 3110 <br />�{ 0 16. Transporter 2 Acknowledgement eF Receipt of Materials - <br />W F Primed/TYped Nome SigmNnn FAordh Day . Yam <br />T <br />{L F <br />O <br />sy 19. Discrepancy Indication Spam ' <br />G F <br />U A <br />Z I <br />_ l <br />' I 20. facility Owner or rotor Cert'dicaRan of rcmi t of hasord.ns matmiaN covered thb manifest except m need in Nem 19. <br />T Primed/Typed Name SiBnaNrc Month Dvy Year <br />DO NOT WRITE BELOW THIS LINE. <br />Disc 8022A (9/95) Yellow: GENERATOR RETAINS <br />EPA 8700-77 <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />Disc 8022A (9/95) Yellow: GENERATOR RETAINS <br />EPA 8700-77 <br />