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State of California—Environmental Protection Agency <br /> Form Appro d,OMB No.2050-0039(Expires 9-30-99) See Instructions on back o" le 6. Department of Toxic Substances Control <br /> Pie nt-6rJype. Form designed for use on elite(12-pitch, vriter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> is not required by Federal law. <br /> -WASTE MANIFEST of <br /> a3'Generators Name and Mailing Address A. State Manifest Document Number <br /> h- <br /> O f'`,03 B(,r", 2105), Ky (r 04 B. State Generator's ID <br /> 41 A. eneraior 4 Phone(c s 4'4 <br /> CN 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID(Reserved.) <br /> LO <br /> 00 <br /> D. Transporter's Phone (510) <br /> o 49-13 90 <br /> \7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] _ <br /> yJ _ <br /> ° < _'. F._�Trpnspaiter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> �}a '.'r.�?:3.`ii3.'+' +� t)'a�:Ft.`#`4JY�° #.�3�.:.. •� �q t - 5„ � ,;$' � a'° � J.630 W.. ..1.STH ST, � H. Facility's Phone '� <br /> ,kip 1_,C`_)i.s f�#;"�.CN, CA 90811 t.. A fl, 1: 4 0 9 d' (562)432-5445 <br /> w�w <br /> } J <br /> Q 12. Containers 13. Total 14. Unit <br /> •' U X111. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. F Type Quantity Wt/Vol I. Waste Number <br /> 4L Za. q State <br /> ~ ` S 0.9t 'fit tC ^SC EPA/Other <br /> 1)CIO Cl 10 VZ lo- <br /> Eb. y <br /> � <br /> 1° 4.411 f. A OSO&S C�L-A PO J�f'�4�) 1� (jN i aU State <br /> 0°0o E ° °° - 1 . <br /> EPA/Other <br /> 4 A C. �,,. State <br /> o T j iifS :` % "F(ja.IC 1-iL�01D, (•Oif 7 �, 4Jr .r <br /> `7•6' RA.f6,' 44Ei~ EPA/Other <br /> 12- DOM <br /> State p <br /> LU d. iCF� SrfE�4 r 4?2 <br /> I£� AST c€r 'FAnvLFD AND To FOR so.st,,,�vT <br /> Z civ 71SPOSAL,TREATMENT OR REUSE CROSBY S OVER--• _ v �-�t�: EPA/Other y 8 <br /> w '' PERMITS GRA"'rM TO-n[EM,BY TftE DEPARTS cY C' T T C E.l. •.`.r; '- S"� Rl <br /> �t ,yam r( •.Pe,�i� <br /> N r t I'f it i .fc1„r lg}texisted Abovg <br /> J AdddionaI Descriptions for Materials-D46diS6 MCE CONSERVA <br /> Z FEDERAL�ASND �>t,TE,REG O � t.OGETk1ER c Tt SC}tELE b , <br /> d 1 iy� U6 �ANITx7t(Ov }LAS All OF <br /> 3 1'S.`� :i ar»� f �4w�t F'.7 £'-'-vl!!$ j �`' r <br /> V) 3 D)' Vit$ ft' ': I�4ACCORDq('0iw Valley Sprftygs t WASTE <br /> t <br /> 15. Special Handling Instructions and Additional Informatigt e <br /> ;., ;,#E��� ##F.I?�'fc�};:].�.)'E; f';°'t'"L:a',�?i�. s-'I:l:�l(.�.]'9w'1•; �:*r��lTr'irP�:9f"t; <br /> Z x 9 'r ): " I� �,.r 1^IIf."1. C.:x..h�'e"]'�'>S:`�• �; ± i. <br /> w r v a T a' r a. f 1 •7 G_ �`3 f: 3 :}a`t A, I.-9 1..C,I <br /> 16.'&NERATbR'S CERTIFICATION: I hereby declare that the contents of this consignment are Fully and accurately described above by proper shipping name and are dBssiFied,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> IF I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and Future threat to human health <br /> N <br /> and the environment;OR,if I am a 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 /> O Printed/Typed Name Signature Month Day Year <br /> w T 17. Transporter 1 Acknowled ement of Receipt of Materials <br /> RY Month Da Year <br /> i _ <br /> LU it Printed/Typed Name Si9nature• <br /> wSv 19"mt! i i C°J6vA ✓;.p °�`x`°4' +c ;. 1. r J <br /> P <br /> u.. B 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> LU E <br /> N R <br /> U19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> I 20. Facilit Owner or Operator Certification of recei t of hazardous materials covered by this mgnifest except as noted in Item 19. <br /> T Printed yped Name Signature Month Day Year <br /> t <br /> y gg <br /> DO NOT WRITE BEL6W THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> 22A (1/99) (Generators who submit hazardous waste for transport out-of-state, <br /> DTSC 80 <br /> EPA 87022A produce completed copy of this copy and send to DTSC within 30 days.) <br /> H. <br />