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State ofCalifornia—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9.30.96) <br />Plea{ , rint or type. Form designed for use on elite (12-pitc.. rifer. <br />O <br />W) <br />L0 <br />r\ <br />CV <br />h <br />C10 <br />O <br />00 <br />J <br />Q <br />U <br />Q <br />Z <br />O <br />C37 Q <br />T -i U <br />Co Z <br />0) _ <br />H <br />CV <br />O <br />co <br />00 <br />4 <br />04 <br />0 <br />O <br />00 <br />LU <br />F - <br />Z <br />w <br />U <br />w <br />V1 <br />Z <br />--0 <br />CL <br />V) <br />w <br />Q <br />Z <br />0 <br />a <br />Z <br />w <br />J <br />Q <br />U <br />a <br />0 <br />r <br />U <br />Z <br />LU <br />0 <br />LL <br />LL <br />LL <br />LL <br />LL <br />C <br />LL <br />V, <br />Q <br />C: <br />Z <br />See Instructions on back ge 6. <br />Department of Toxic Substances Control <br />DO NOT -WRITE BELOW THIS LINE. <br />Yellow: TSDF SEND$ THIS COPY�O GENERATOR WITHIN 30 DAYS. <br />(Generators 'who submit.hazardous waste for transport out-of-state, <br />DTSC 8022A (1/95) produce corn pleted-C-5-py of this copy and send to DTSC within 30 days.) <br />EPA 8700-22 <br />UNIFORM HAZARDOUS <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />WASTE MANIFEST <br />L J <br />is not required by Federal law. <br />0 q <br />:f i <br />1 of 1 <br />3. Generator's Name and Mailing Address y�-7•� '7l � <br />/ <br />A. State Manifest Document Number _ <br />N; <br />fit/ • 6-44< ---1 %t% 7 <br />')_ <br />� � � � <br />B. State Generator's ID <br />_ (� 0 .e� <br />LO, y V <br />4. Generator's Phone ( ) S%�OG" n� tv� Y�'2G <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID <br />BDC-FALCON <br />D. Transporter's Phone <br />p tA1B) a#.r?-13 i4 <br />SPECIAL WASTE SEROICFCAR tJ i1 1171-61-d <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID <br />F. Transporter'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 />ro T3 9 9 0 7 .4 1.." -3 _.._._ <br />9999 SOUTH AUSTIN 'RD <br />H. Facility's Phone <br />MANTECA, CA 955336 1 CAD 191910 17 9 4 <br />1 3 <br />(20919e4 - L9E1 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />14. Unit <br />No. <br />Type <br />Quantity <br />Wt/Vol <br />I. Waste Number <br />a <br />State 151 <br />r <br />R.0. ASBF_STOS, 9, NA 2212, PGIII (NAERG#171) <br />I <br />f <br />,/ <br />EPA/Other <br />E <br />N <br />b. <br />State <br />E <br />EPA/Other,,< <br />R <br />A <br />' <br />T <br />c• <br />State <br />O <br />EPA/Other <br />R <br />d• <br />State <br />EPA/Other' <br />J. Additional Descriptions for Materials Listed Above <br />_ .. <br />K. Handling Codes for Wastes Listed Abovea. <br />- - - <br />FP 1 f�BLE ASDESTf S CU?vTP.IC! I� i(� RAST <br />c. cl <br />15. Special Handling Instructions and Additional Information <br />2j HRS. EMERGENCY <br />1-500-535-5053 �} PPAVA J <br />BDC-FALCON 765 SOUTH AYON AZUSA, CA 91702. <br />!!,, <br />EPA REG -10N IX -75 HAWTHORNE ST. ..SAN FRANCISCO, CA 941135 `� S� V <br />QQ 2F T' c Cir flnl �t1 ,f h T t .CTS C.P7 <br />gr r . <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper ;Niing name and are classified, <br />packed, marked, and labeled, and are in all respects in proper condition for transport by highway <br />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 <br />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 generation and select the best <br />waste management method that is available to me and that I can afford. <br />Printed/Typed Name <br />Signature_ <br />% __... <br />Month Day Year <br />12 <br />T <br />R <br />17. Transporter 1 Acknowled ement of Recei of -Material's r <br />f <br />A <br />Printed/ d Name <br />/T7�' %�✓�' <br />Signature <br />Month Day Year, <br />S <br />i <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />R <br />F <br />19. Discrepancy Indication Space <br />A <br />C <br />\ <br />1 <br />20. Faci ity Owner or Operator Certification of receipt of b6zardous materials co red by this manifest <br />exce t'as noted in Item L9. <br />T <br />Y <br />Pri ed /Typed Name ( <br />Si r <br />Month ^ Year <br />:. i / �f r' / `.'tom <br />� %•(/ [- L_ <br />- <br />DO NOT -WRITE BELOW THIS LINE. <br />Yellow: TSDF SEND$ THIS COPY�O GENERATOR WITHIN 30 DAYS. <br />(Generators 'who submit.hazardous waste for transport out-of-state, <br />DTSC 8022A (1/95) produce corn pleted-C-5-py of this copy and send to DTSC within 30 days.) <br />EPA 8700-22 <br />