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Z�Environmentcsl Protection Agency A, <br /> 1 <br /> ed OMB No:2050-4039(Expires 9.30-96) S@@ Instructions OA bOCtc Of ! 6. Department of Toxic Substances Control <br /> /or type. Form designed for use on elite(12-pitch), ler. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas c <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST CIAICIOA01 112101110191 3 41 5 .ti 1 ? of 1 ] <br /> 3. ator' nd 1 Address A. State Manifest Document Number i l <br /> a ,l."' . ,fit 0"l�PL��� SAt4F <br /> 2325' WEST CHARTER WAY i <br /> STOCKTON,-CA. 95206 B. State Generator's,1D <br /> f 0 ( <br /> ? r+ Cr �� <br /> 209467-0490 _ <br /> to A. Generator's Phone (.op <br /> : ) <br /> O 5. Transpoq!rj Company Name 6. US EPA ID Number C. State Transporter's ID <br /> R D 000 .7 65 <br /> BL�rfil 9- Ne CAD 9 8 1 4 5 S 5 Z 6 D. Transporter's Phone - _c <br /> J a <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> F. Transporter's Phone <br /> Q r G. State Facility's ID <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number tY <br /> � -. sF�Cg�lRgl�9AgRD INC.(� flit II. <br /> f CRA 5:3 RD C A r� 9 ? ; 4 .i H. Facility's Phone i. ; �E <br /> 12. Containers 13. Total 14. Unit <br /> I1. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> Quantity Wt/Vol I. Waste Nvmberype _ <br /> State r..; <br /> Mt: <br /> 3 R.0. ASBt=STOSV 9 NA22I2` PG IIT. t ' <br /> EPA/Other Jam' l- C 07� -�P 1242 <br /> o� 1�0 - b._. State <br /> N -- --- -.. ---- --- --- —. -- -, <br /> v <br /> C ".t: EPA/Other <br /> RI <br /> 0 <br /> A <br /> O T c. State <br /> R MAY, 1 1997 EPA/Other a <br /> W <br /> Z d. BY: - State <br /> W <br /> EPA/Other <br /> N <br /> "Z J.'Additional-Descriptions for h(riferials Listed Above K. Handling Codes for`Nostes Listed Above <br /> b. <br /> W 1• ..�.. - <br /> c, d. <br /> J <br /> Q 15. Special dl ` gructtonspnd-Additional Information 24 HRS. EMERGENCY <br /> Q EDC , 7x+36 SOUTH AYON AZUSA, CA.91702 <br /> Z Z,5 Sr` <br /> W EPA RECTION IX BAA014D- 939 SF CA 9yr's Q.B. REBUILDERS <br /> ASBESTOS REMOVAL REQUIREMENT- 40-'CFR 61 (BAGGED. SEALED P.ND LABELED) <br /> Zd <br /> 16. GENERATOR'S CERTIFICATION:-I hereby declare that the`contenits of this consignment are fully and accurately described above by proper shipping name and are classified, <br /> Q packed,marked,and labeled,ani are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> U <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 /> J <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 /> CL I <br /> N threat to human health and the environment;OR, K I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br /> v. waste management method that is available to me and that I can afford. <br /> O Printed/Typed Name _Sigrwtur_a --- / Month Day Year <br /> U 7t r'-Affil A/P C AA A /Z `t r Ll T��. C <br /> Z 1 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> W A ay Printed/ y,ted Name Signature Month DYear <br /> 7O15ww - rter 2 Aknowldeent of Receipt of. rvns <br /> Materials <br /> LL T Printed/Typed Name <br /> Signature Month Day Year <br /> O E <br /> R <br /> N19. Discrepancy Indication Space <br /> QF <br /> U A <br /> Z C <br /> I <br /> L <br /> 20/. Foci f Ownerlore�Operator Certification <br /> of receipt of hazardous material overed b is monife exce tAiK,6otecl in Item 19. <br /> Y P No P <br /> w ' Month /Day 7,r7. <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> 1 95 (Generators who submit hazardous waste for transport out-of-state, <br /> DTSC 8022A <br /> ( / ) produce completed copy of this copy and send to DTSC within 30 days.) <br /> EPA 8700-22 <br />