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4'4• WNr4 °1 <br /> HAZARDOUS WASTE <br /> MANAGEMENT REPORT <br /> State Of California 4250 Power Inn Rd.,Sacramento 95826 <br /> (916)739-3145 <br /> Department of Health Services 5545 E. Shields Ave,Fresno 93727 <br /> Hazardous Waste Management Branch (209)291-6676 <br /> 2151 Berkeley Way, Berkeley 94704 <br /> (415)540-2043 <br /> Date -t- / ) '> <br /> 107 S.Broadway,Los Angeles 90012 <br /> (213)620.2380 <br /> Firm Name <br /> Address <br /> EPA I.D. No. 7 . <br /> ❑ Facility ❑ Hauler Q Producer <br /> Person Interviewed ❑ Other <br /> The following conditions or practices observed this date are alleged to be violations of one or more sections of the <br /> California Health and Safety Code, Division 20, or the California Administrative Code, Title 22, relating to the <br /> storage, bandling, transportation, and disposal of hazardous and extremely bazardous waste or asbestos containing <br /> products. The inspection and the collection of samples or otber evidence, including the taking of pbotographs, was <br /> conducted under autbority of Section 25185, California Health and Safety Code and Section 66328, California <br /> Administrative Code. <br /> r.. i <br /> i <br /> Your signature acknowledges receipt of a copy of this report and collection of any samples described above. <br /> ,', i ::. � �+'` i " ( --'�.� "i J� a/'�r%✓fit./2•T�1�-�:r( L C.( /�{(,,Zk' �.N-,-: �? ;:i.<�,e�C. <br /> Authorized Representative of Firm C.t,v,i_,�t < ;!�,��; .�,�.• .? . <br /> Name Authorized Agent <br /> ' <br /> Title rr �.r•j.F' f i �t_�l.l i i :�`)/�fr 1 �, <br /> EH 202(12182) Page_ of_ <br /> 8019-002 <br />