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See Instructions oW lidck'of page 6. Department of Toxic Substances Control <br /> t 12-pitch)fy r. _ Sacramento,California <br /> .n HAZARDOUS 1. --.erotoei US EPA ID No. Manifest Document No. 2. Pagel t Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE,MANIFESTof / <br /> 3. Generator's Name an Mailin Address tuber <br /> cR B Re�u��1e 9247 <br /> LO <br /> �/ <br /> tr1 �•G(f ���� .Z �Q/ B, Stoie Generators ID <br /> N a nefator�hone(!L 1 .� f <br /> LO v ^t C <br /> 00 <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C: State Transporter's ID <br /> 000 >,Trons rler''s Phone- <br /> e•- l.11� SERVICES, INC 1 - 5 2 � t_lt ii.�LS zJ.. �,_�'i� ' <br /> 7. Transporter 2 Company Name 8. US EPA ID Number tate 7ranspo ter's 1D <br /> VQ <br /> V ransporter s.Phone <br /> Q 9. Designated Facility Name and Site Address 10. US EPA ID Number :Stcte Facility's ID <br /> OZ FORin1ARD INC. 17 1--: <br /> `0 H. Facility's Phone <br /> 9999 SOU.PH AUSTIN ROAD <br /> M1�NT'DCA CA, 95336 9 9 0 7 9 4 1 3 3 - " 7 <br /> V12. Containers 13. Total 14. Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) Na. Type Quantity Wt/Vol 1. Waste Number <br /> Z <br /> — State- <br /> 77 3 "R Q." HAZARDOUS SUBSTANCE SOLID N.0.S <br /> G ORM E NA 9188 (,ASBESTOS) EPA/Other <br /> NE State —�— <br /> 000 N b <br /> 0 <br /> 00 E EPA/Other <br /> cw R <br /> A DSta e <br /> opo =T C. <br /> O - EPA/Other <br /> JU <br /> LU <br /> R Stale <br /> t- d. <br /> w1 <br /> V _ FPA/Other <br /> { w <br /> r._ _,._ <br /> --.z _.. __.._ -__._--- --_ K.`Han�fing`Codes for Wastes Csted Above <br /> O— -' .A�dditienal Descriptions forJl�cFBridis-Gste'd Above' -' <br /> a b. <br /> w T1 � 1Vf�� � X <br /> S �tiNLY d. <br /> TYE <br /> J r, <br /> Q - ..rte•: a� <br /> 0 3..`i 5013 <br /> Z <br /> 0 15. Special Handling Instructions and Additional Information <br /> a ` BDC SERVICES, INC ASBESTOS REMOVAL REQUIREMENP 40 CFR 61 <br /> Z 766 SOUTH AYON AVE. (BAGGED, SEALED AW-LABELED) <br /> LU AZUSA, CA 91702 <br /> �- <br /> J 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br /> J packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable federal,state and international laws. <br /> Q <br /> V ' <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 <br /> economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> N <br /> threat to human health 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 <br /> _waste management method that is available to me and that 1 can afford. <br /> Signature <br /> Month Day Year <br /> 0 Printed/Typed Name g <br /> V ../` <br /> Z T 1 . rens orter 1 Ac nov+e nt o ecei t of Materials <br /> LU Signature Month Day Year <br /> 0 .-A Printed/Typed Name <br /> S <br /> W - p- - - ... <br /> 0 18. Tra orter 2 Ackno ed emen of Recei t of Materials <br /> Printed T ed Name Signature Month Day Year <br /> w '-x / YP <br /> U- E <br /> 0 R <br /> LU 19. Discrepancy Indication Space <br /> Q F t, ` <br /> V A <br /> Z_ C <br /> I <br /> 1 20. FacilityOwner or Operator Certification of receipt of hazardous materials covered b is monifest/exce t noted in Item 19. <br /> T Printed/Typed Name Signature % Montlh Day Year <br /> Y / 011 <br /> (LJ <br /> 0 <br /> DO NOT WRITE BELOW IS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> 22A (7/92) (Generators who submit hazardous waste for transport out-of-state, <br /> DISC 80produce completed copy of this copy and send to DTSC within 30 days.) <br /> EPA 87022A <br />