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State of California-Environmental Protection Age�L-y
<br /> fmn,00prov*OMB No.2050-0039(Expifes�9.30.99) See Instructions on back of 6. ��ZI�ID`�
<br /> PleasBrio}6�199 e. Form designed for use on elite(12-pitch]h or. epartment of Toxic Substances Control
<br /> Sacramento,California
<br /> UNIFORM HAZARDOUSTr-1
<br /> Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas
<br /> WASTE MANIFEST is not required by Federal law.
<br /> T3—. Generotor's
<br /> AD f) $ 3 6 (? f3 U 5 L 'r :> ¢ rt 3 of �,.
<br /> Name and Mailing AddressA. State Manifest Document Number
<br /> T !`�� '� " 23452453
<br /> .O. BOX 24055, AIS ')U 4
<br /> �0 0Aic'4'.A D, CA 9462..3_1,.05.5 B. State Generator's ID
<br /> A. GeneraTor's Phone (510
<br /> N 5. Transporter 1 Company Name
<br /> LO 6. US EPA ID Number C. State Transporter's ID[Reserved.]
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<br /> o FOSS EhiVTRONME NTAL SER.VIC.ESp 0 0 ! Q 1 1 4 D. Transporter',Phone �51i1�749-�1,�9f1
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<br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter',ID[Reserved.]
<br /> j�Q F. Transporter',Phone
<br /> V pested Fac li and Site ddrs
<br /> NC
<br /> 10. US EPA ID Number G. State Facili ID
<br /> 163011. 17THsT. L 1C. Dt12840901 19
<br /> T O U)INi BEACH, CA 90813 A D o o 8 4 0 9 0 1 9 H. Facility's Phone
<br /> (562)432-5445
<br /> US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12• Containers 13. Total 14. Unit
<br /> V I�Aq P ( 9 P PP 9 No. Type Quantity Wt/Vol I. Waste Number
<br /> a' 1IN hI�T E 1tj L F 0,C l 5, E i f?rl/f All Iq i,t[` 2. 1, oS 19 5 0 State 14
<br /> y E D / 1 D 11 fn (� EPA/Other D00
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<br /> o N �. b. W�JtE. 6fl'r'fCk3(.S, WET, F ..[ LLC0 W3� ht.j �CiL'�r State ���
<br /> co R '�� Q, ��2 79�! f' I_ 0002, D000 �. �112 t?v©f .
<br /> + EPA Other
<br /> A ( T 010 f r_, W f O 0 f
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<br /> a R JAJ32 E,q Pij f 10 f P I/A 0 P 6 PJ EPA/OtherDO07-
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<br /> d. lni�}.STE PAINT fZ[ (4TUP M g7ErZ11L/ State 3�f
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<br /> v rl 3, V f� )2 C^3, P�7C 01011 A!t Ci C7 i� EPA/Othe�OtJ
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<br /> Lo J. Additional Descriptions for Materials Listed Ab ve K. Handling C des fo Wastes Listed Above
<br /> Z 1 Site:- i. ..
<br /> )><r0 .-
<br /> p IIA) 33' 1" ff7h'_1Z. f ) Pardee Ctr. a. / L � b.
<br /> w 11+3 3}353 61� : t S'f tl r 5!111 'V'al ley Springs. CA 55252
<br /> tic lf' W7-0� E"1ZEI� 14w x10 d.
<br /> z of 0 C P2 —02. E R Ej: 12$ f 1r►o (�
<br /> O 15. Special Handling Instructions and Additional Informo0gg �fRE APPIROPRIPTE PERSONAI, I'i (APEOTTVE EQUi PhE�d`l:`
<br /> Z 24-MR. EMEW;FNCY CONTACT: ftnf Pow�s��vr��1`f�^,o�fs Iry
<br /> LU E'OSS ENV"CFtONAfE�1TAI, (`�10)1���'""X0,VM n�i0I asi► 4 - , PC�1Y: AP40k)18•-"1
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<br /> Q16. GENERATOR'S CERTIFICATION: I hereby decla dEhDttF418e pR�iM MIFe Lrid@��' shippping name and are classified,packed,
<br /> V marked,and labeled,and are in all respells in prop t�n a p� WSay�E�i to1N IeSfMgrin� oThe C I rnment regulations.
<br /> j ��05a Y CT pp ig 6ATCF Wil 7)',"Rp r uNp&R
<br /> If I am a large quantity generator,I certify that I have a program in place to reduce the vo Jf�agg��x�t Af y�s�dd t 0*J a determined to be economic a III
<br /> N practicable and that I have selected the practicable method o treatment,storage,or disposal currently a�Aal o eAlkic i t and Future threat to human health
<br /> and the environment;OR,if I am a small quantity generator, I have made a good faith effort to minimize my wast �Ift, $� 11 h-Tt waste management method that is
<br /> Oavailable to me and that I can afford. BQiN Shy
<br /> r Printed ed Name t Si na r r -'
<br /> Month Day Year
<br /> N17. Transportrer 1 Acknowledgement of Receipt of Materials TO,
<br /> Lu A Printed/Typed Name Signature
<br /> R r 9 �„ ..�'�-^ Month Day Year
<br /> Lu P T N L Ft T20 vv' .�1�'at arc �G 2 I 0
<br /> R18. Transporter 2 Acknowledgement of Receipt of Materials
<br /> 1 Printed/Typed Name Signature Month Day Year
<br /> LU E
<br /> sn R
<br /> V F 19, Discrepancy Indication Space
<br /> Z A
<br /> C
<br /> I
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<br /> 20 Facility Owner,4r O er for Certification of receiorbf hazardous materials covered by this manifest except as noted in Item 19.
<br /> T Pr' ted/Typed Nome Signature i
<br /> 1l(...- if —7 1 1
<br /> Month Day Yeaf
<br /> DO NOT WRITE BELOW THI,_,CINE.
<br /> tow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS.
<br /> DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-of-state,
<br /> EPA'$000-t'82l produce completed copy of this copy and send to DTSC within 30 days.)
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