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State of California—Environmental Protection Agency' <br />Form Approved OMB No. 2050-0039 (Expires 9-30.99( <br />Please print or type. Form designed for use on elite ( 12 -pitch) r. <br />0 <br />h <br />N <br />on <br />OF <br />c <br />C <br />cc <br />Q <br />L <br />�a <br />172 <br />rrt u <br />Vel <br />l.n 3 <br />h <br />s�c <br />c <br />c <br />c <br />c <br />c <br />c <br />I <br />t <br />1 <br />i <br />See Instructions on back of b. Department of Toxic Substances Control <br />Sacramento, California <br />`-- DO NOT WRITE'B-FLOW TK1bWNt. , <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-of-state, <br />DTSC 8022A (4/97) produce completed copy of this copy and send to DTSC within 30 days.) <br />EPA 8700-22 <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />is not required by Federal law. <br />WASTE MANIFEST <br />1.of <br />Q1 Al 01 21 01 1141: 191 <br />3. Generator's Name and Mailing Address <br />A:' State Manifest Document Number�y Pq -y f <br />`�+ 5 <br />QB REBUILDERS vr; <br />V i <br />2325 WEST CHARTER MAY. S ITE -SAME <br />B. State Generator's ID <br />STOCKTON, CA 95206 � <br />H ',, H Ia 36 0121419 1 5 <br />4. Generator's Phone ( 209) 467-0490 <br />I <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID <br />BDG SPECIAL <br />G WASTE r. A R 010101 ► i 7 ±1 5; <br />D. Transporter's Phone r 2f-) 9" - -- — ^� y <br />6.�,� _n�3 i.�n� <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. Stare Trcnsporter's ID <br />- <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State ocil,�ty'l ID L� (^{ 1 v i, ``_•, <br />FORWARD INC. - APPROVAL #525520() <br />Q 9999 SOUTH AUSTIN RD CA S 0 Q 0 i O (� <br />=1�t <br />H. Facility's Phone_ <br />' <br />}982--4'"-93 <br />MANTECA, CA 95336 <br />12. Containers <br />13. Total <br />14. Unit <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />No. <br />Type" <br />Quantity <br />Wt/Vol <br />I.. Waste Number <br />- <br />State <br />151 _ <br />R. Q. ASBESTOS, 9, NA 2212, PGI I I (NAERG#171) <br />e m <br />a <br />y <br />EPA/Other <br />G <br />t E <br />b. <br />State <br />> N <br />EPA/Other <br />E <br />r R <br />A <br />a _ <br />State - <br />> T <br />EPA/Other <br />O <br />- R <br />State <br />d. <br />EPA/Other <br />Additional Descriptions for Materials Listed AboveFRIABLE. <br />Codes for Wastes Listed AboveJ. <br />ASBES-TO�� CF3NTRINING i'J'ASTE <br />Tling <br />d. <br />u <br />>c <br />J <br />D15, <br />Special Handling instructions and Additional Information P4 HRS. EMERGENCY 1-800""535"5053 <br />< <br />E S <br />LA 7 <br />NUrA <br />5 5 F AN OB R _B <br />�PVOASBESTOS <br />_ <br />REMOVAL RECQUIREi+iAT 40CMIIBAGGED,SEALLD & LABELED) <br />Q <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed, <br />labeled, in in condition for transport by highway according to applicable international and national government regulations. <br />U <br />marked, and and are all respects proper <br />IF I am a large quantity generator, I certify that I have a pr ram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br />storage, or disposol currently available to me which minimizes the present and future threat to human health <br />a <br />practicable and that I have selected the practicable method of treatment, <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 />0 <br />available to me and that I can afford. <br />` Month Day Year <br />Printed/Typed Name / Signatu a 1 J�j �t 7q <br />y <br />z <br />�. <br />�'-1!//��� �I/ r / (/ !J <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />/ Month Day Year <br />w T <br />D <br />W p <br />Prince ped Nome Si nature - <br />/ V <br />� N <br />w S <br />CLU <br />jjjv <br />P <br />LL- 0 <br />18. Transporter 2 Acknowled ement of Receipt of Materials Month Day Year <br />0 T <br />Printed/Typed Name Signature <br />Lu E <br />Cn <br />R <br />V19. <br />Discrepancy Indication Space <br />Z F <br />— A <br />C <br />I <br />L <br />I <br />20. Facili Owner or Operator Certification of receipt of hazardous materials covered b t ' no es etas noted in Item 19 J M wh y Y <br />T <br />T <br />Printeti9T ed Name Signature f <br />� <br />F �� <br />i �Zk <br />`-- DO NOT WRITE'B-FLOW TK1bWNt. , <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-of-state, <br />DTSC 8022A (4/97) produce completed copy of this copy and send to DTSC within 30 days.) <br />EPA 8700-22 <br />