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State cif California -'+Environmental Protection Agency " <br />.•r,FormApproved OM, No. 2050-003.9 (6pios-9-30-99) " <br />Please print or e.` Form.designed for use on elite (12 -pitch) 7r <br />C, <br />C <br />a <br />a <br />C, <br />C <br />C <br />a <br />Cs <br />LL <br />r <br />LL <br />LLLL <br />L <br />L <br />LL <br />a <br />L <br />C <br />t - <br />C <br />C <br />C <br />r <br />c <br />L <br />c <br />L <br />L <br />" See Instructions on back of 6. Department of Toxic Substabces'Control <br />der Sacramento, California <br />THIS WASTE STREAM HAS BEEN QUALIFIED DO NOT WR(TE 'BELOW iTHIS L E. <br />FOR RECYCL AT THE D/K <br />ENVIRONMENTAL/TREATMENT FACILITY N VERNON, CA. <br />Yellow: SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />THIS FACILITY HAS THE NECESSARY PERMITS (Generators who submit hazardous waste for transport out-of-state, <br />TO RECEIVE YOUR WASTE STREAM AS QUALIFIED• produce completed copy of this copy and send to DTSC within 30 days.) <br />OUR EPA NCAT080033681. <br />U FORM HAZARDOUS <br />1 Generator's US EPA ID No. .. "t Manifest Document No. <br />• <br />2. Page 1 <br />Information in the shaded areas <br />is not required by Federal law. <br />ASTE MANIFEST <br />; '; , <br />of 1. <br />3. Generator's Name and Mailing Address <br />A. State Manifest Document Number <,. <br />Q8 .EBurLD Rs <br />J97. 6 68.21 <br />B. State Generator's ID <br />23 Wl • CHARTER WAY STOC ON, CA 9520E <br />4. Generator's Phone (20.9 ) 467-049 <br />-� <br />... <br />__5.. Transporter 1 Company Narie 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.] <br />:: <br />D. Transporter's Phone <br />'QLGC <br />7.• ransporter cmpany dme 8. S PAID um er <br />E. StateTransporter's eserved. <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State FaciliVs ID <br />019EVVIRONMENTAL <br />s - f <br />.H. -fact ity's Phone-...- _...:', .,,..........-:.-....... _ <br />3650126TH STREET <br />I QS CA 0OR13{ <br />- <br />- " <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) _ <br />1�04,�13. <br />Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />I. Waste Number <br />a.. <br />State <br />HAZARDOUES WASTE SOLID N.O.S <br />q e; <br />EPA/Other <br />' <br />G <br />(CADMIUM) 9, NA 3077 P.6, t <br />t2 <br />4 <br />� <br />E <br />6.State <br />IRCRA <br />E <br />E <br />NON HAZARDOt/S WASTE SOLID <br />359 <br />EPA �ther T <br />R <br />(OILY DEBRIS) <br />01012- <br />Q© <br />P WF <br />T <br />C. - -�-..��T <br />State; <br />NON RCRA HA�DOUS WASTE SOiZ� <br />EPA/Other/' <br />�'" <br />R <br />(,OILY SOLID)nnoz <br />.. <br />^ <br />(J <br />;� <br />d.• V 91I <br />State <br />EPA/Other <br />�J <br />J. Additional Descriptions for Materials:Listed Above-: <br />K. Handling Codes for Wastes <br />Listed Above <br />6. <br />1.1b. 300202-52 <br />�. <br />d. <br />f1c. 300203-02`:,-' <br />j <br />15. Special Handling Instructions and Additional Information <br />• <br />Jr_, b =F <br />APPROPRIATE' CLOTHING <br />' <br />24 HOUR EMERGENCY RESPONSE - CHEM TEL, INC. 1-800-255-3924 <br />i <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 for by highway to applicable international and national government regulations. <br />marked, and and are all respects proper condition transport according <br />If I am a large quantity generator, I certify that I have a program in place to reduce the volume and <br />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 />and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize <br />my waste generation and select the best waste management method that is <br />available to me onc{,,,that I can afford. <br />' <br />Pri d/Typed Name <br />Sign re <br />Month Day Year <br />100 <br />2. 49 <br />T <br />1 . Transporter 1 Acknowledgement ci t of Materials <br />R <br />A <br />rinted/ yped Name /�,//�,,,,��//// <br />Si r <br />Month Day Year Year <br />T— <br />o Z v <br />i <br />P <br />NII 12,0J' <br />U <br />D <br />18. Transporter 2 Acknowled e t of Receipt of Materials <br />- <br />R <br />1 <br />Printed/Typed Name / <br />Signature <br />Month Day Year <br />R <br />j19. <br />F <br />Discrepancy Indication Space <br />ra N wO"b Av, p,S (Ca oti-�.-+rte C- A-, ►^ � <br />1 • <br />L <br />0. Facili Owner or Operator Certification of receipt of hazardous matepiale covered by this manifest except as noted in Ikm 19. / <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />Y <br />c, <br />�Z f i <br />THIS WASTE STREAM HAS BEEN QUALIFIED DO NOT WR(TE 'BELOW iTHIS L E. <br />FOR RECYCL AT THE D/K <br />ENVIRONMENTAL/TREATMENT FACILITY N VERNON, CA. <br />Yellow: SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />THIS FACILITY HAS THE NECESSARY PERMITS (Generators who submit hazardous waste for transport out-of-state, <br />TO RECEIVE YOUR WASTE STREAM AS QUALIFIED• produce completed copy of this copy and send to DTSC within 30 days.) <br />OUR EPA NCAT080033681. <br />