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State of California—E"ronmental-Protection Agency ��l <br />Qgts.ti�'proved OMB No. 2050-0039 (Expires 9.30-96)? Cpn 5T See Instructions on back <br />Please print or type. Form'designed for use on elite (12-pitr. riter. <br />O <br />In <br />LO <br />n <br />CV <br />L0 <br />tl0 <br />00 <br />d <br />O <br />J <br />a <br />C) U <br />�a <br />CfJ O <br />LL <br />CT) a <br />U <br />LO Z <br />F <br />3 <br />CN <br />0 <br />cc <br />00 <br />-4 <br />(V <br />0 <br />0 <br />m <br />M <br />W <br />Z <br />LL <br />U <br />LL <br />Z <br />--c <br />a <br />V7 <br />W <br />M <br />a <br />L <br />a <br />V <br />tY <br />C <br />L <br />Z <br />LL <br />C <br />rr <br />LLLL <br />LL <br />LL <br />C <br />LL <br />V <br />a <br />L <br />Z <br />'ye 6. Deportment of Toxic Substances Control <br />DO NOT WRITE BELOW THISLIME. \, <br />Yellow: TSDF SEN S THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit,hazardous waste for transport out-of-state, <br />DTSC 8022A (1/95) produce �o <br />EPA 8700-22 ��mpleted copy of this copy and send to DTSC within 30 days.) <br />UNIFORM HAZARDOUS <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />11 f9rm6tion in the 'shaded meas <br />WASTE MANIFEST <br />Js not required by Federal law. <br />A `� L 7 /r 1 m <br />of <br />l�� Ur / <br />3. Generator's Name and M ' ing Address <br />► <br />A. State Manifest Docume <br />Number / <br />� �, �t <br />tu 963 :0 <br />�W a>✓ <br />B. State Generator's ID <br />4. Generators Phone (' ) <br />5. Transporter 1 Company tame 6. US EPA ID Number <br />C. State Transporter's ID <br />BDC_'--F-ALCOtN <br />D. Transporters Phone <br />(818)96'-1384 <br />SI'>=CIPL I:ASTE SEF;UICES R �7f a 1 7 r'i 5 r <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID <br />F. Tronsporter_s Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />FORWARD INC. <br />IC I A I D 199 10 <br />17 19 14 1 13 13 <br />3999! SOUTH AUSTIN RD <br />H. Facility's Phone <br />MAN 'ECA, CA 95336 CAD 9 9 0 7 9 4 1 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />' <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />I. Waste Number <br />No. <br />Type <br />a. <br />State c 1 <br />R. Q. ASBESTOS, 91 !NA 2212, PGI I I (NAERG#171) <br />EPA/other <br />G <br />N <br />b• <br />State <br />E <br />EPA/Other <br />R <br />A <br />T <br />C. <br />State <br />O <br />RT <br />-X~ <br />EPA/Other <br />d K—F 12 3 1997 <br />`�*� <br />State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above _ _ <br />K. Handling Codes for -Wastes <br />Listed Above <br />b. <br />C. <br />d. <br />15. Special Handling Instructions and Additional Information F.hI j S'(~ h[jF P1CY 1 `$117—J3_ <br />DDC-Ffil-CON 766 SOUTH AYON AZUSA, CA '31702 <br />GPA REGION IV -75 HAWTHOR,NE ST., SAN FRPON-C I SC,O, CA 'D41.135 <br />ASU STOS RE00M. REQU I RFMEN 1 40C FQ61 (RAGGED. SEALED t I. -A& -'LED, <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper <br />shipping name and are classified, <br />packed, marked, 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 <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 />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 <br />generation and select the best <br />waste management method that is available to me and that I can afford. i ,n <br />Printed/Typed Name <br />Signature ' `j" / _ <br />Month Day Year <br />IF <br />A Z& <br />' <br />R17. <br />Transporter 1 Acknowledgement of Receipt of Materials i -17 <br />A <br />11 <br />Printed Typed ame <br />Signature/ % /� % , <br />Month Day Year <br />S <br />177, <br />0 <br />18. Transporter 2 Acknowled ement of Recei t of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature - <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space - <br />F <br />rte` <br />I <br />L <br />-f <br />20.) Focili Owner or Operator Certification of receipt of hazardous materials covered bf thii manifest except as noted irv"Item <br />T <br />Y <br />inted/Ty ed Name % / �/j/,_ <br />` Y +/ Lt/r' <br />Sig hire �( �� �/ / <br />1 �t/ T y— \ AMU-) <br />Moalh' Day_ G� e <br />�� J <br />DO NOT WRITE BELOW THISLIME. \, <br />Yellow: TSDF SEN S THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit,hazardous waste for transport out-of-state, <br />DTSC 8022A (1/95) produce �o <br />EPA 8700-22 ��mpleted copy of this copy and send to DTSC within 30 days.) <br />