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i' <br />State oaliFornia—Environmental Protection Agency <br />Fo pproved OMB No: 2050-0039 (Expires 9-30;99) / ^ <br />P7etlse print or type. Form designed for use on elite (12 -pitch) ty er. <br />UNIFORM HAZARDOUS 1. Generator's US <br />0 <br />L0 <br />u0 <br />r*1 <br />N <br />co <br />0 <br />0 <br />—,Q <br />SIN <br />N <br />0 <br />m <br />m <br />CV <br />v <br />0 <br />0 <br />ao <br />Z <br />LL <br />C: <br />LL <br />Cr. <br />C <br />v <br />LL <br />C, <br />LL <br />F <br />a <br />v <br />a <br />C <br />See Instructions On back Of ! 6. Department of Toxic Substances Control <br />Sacramento. California <br />DO NOT W�TE BELOW THIS LINE.— <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />DTSC 8022A (4/97) (Generators who submit hazardous waste for transport out-of-state, <br />EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />EP,A7ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />WASTE MANIFEST <br />e "1 G <br />is not re aired by Federal law. <br />412 <br />t. 9 <br />1°f 1 <br />S7 s b <br />3. Guatc ' NNi <br />pg Lt MO 9 Address <br />A. State Manifest Document Number <br />2325 CHARTER WAY SITE: GAME <br />9661701.9 <br />STOCKTON, CA 95206 <br />B. State Generator's ID <br />A. Generator's Phone ( 205 467-0490 <br />I Y 19 Q I �7 <br />5. Transporter 1 Company Name , 6. US EPA ID Number <br />C. State Transporter's ID <br />�.� l <br />BDC—FALCON <br />D. Transporter's Phone �� f (n i i9•) r}F 91_ 13119 4 <br />v V/��== ��- <br />SPECIAL WASTE SERVICES CRR 0 11101 0 11 71 <br />6151 <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. — APPROVAL #525520 <br />1 C1 q DI 9 '31 0 71 91 41 1 ` 3 <br />9999 SOUTH AUSTIN RD <br />`7 <br />H. Facility's Phone <br />MANTECA, CA 95336 C A D 9 9 0 9 4 <br />1 3 <br />r (;�U20_ �) 982-4�� 9 8 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />' <br />14. UnitNo. <br />Wt/Vol <br />I. Waste Number <br />Type <br />a. <br />State 1'w <br />R. Q. ASBESTOS, 9, NA 2212, PGI I I (NAERG# 171) <br />EPA/Other <br />G <br />/ <br />M <br />O D <br />, <br />Nb. <br />State <br />E <br />EPA/Other <br />R <br />A <br />T <br />CC a <br />State <br />O <br />1R <br />EPA/Other <br />R <br />r <br />d. 4" <br />State <br />EPA/Other <br />1. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />FRIABLE ASBESTOS CONTAINING WASTE <br />d. <br />15. s eLaC HFOXndO <br />I information `rl'ftKL�.dL> —80 — �`,-50nLEN 76' SUTH <br />AZUSA, CA 91702 <br />EPA REGION IX -75 HAWTHORNE ST. SAN FRANCISCO, CA <br />94105 QB REBUILDERS <br />ASBESTOS REMOVAL REQUIREMENT 46CFR61(BAGGED,SEALED & LABELED) <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the coolants of this consignment are Fully and accurately described above by proper shipping name and are classified, packed, <br />marked, and labeled, and are in oil respects in proper condition for transport by highway according to <br />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 economically <br />practicable and that I have selected the method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health <br />practicable <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 />available to me and that I can afford. <br />Printed/Typed Name/ <br />Signature <br />Month Day Year <br />f, o Y o// -;?4,/1- <br />/ <br />110 91 01 11 <br />T <br />17. Transporter 1 Acknowledgement of 5fceipt of oterials i <br />R <br />S <br />Printe Typed me /7 <br />I <br />Signature <br />^ <br />Month Day Year <br />l U U <br />018. <br />Transporter 2 Acknowledgement of Receipt of Materials <br />`. <br />TPrinted/Typed <br />Name -r ""'-- <br />Signature - <br />�� - <br />-Month Day - Year <br />E <br />R <br />19. Discrepancy indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />20. Facility Owner cLr Operator Certificatioftf receipt of hazardous materials covered by this ifest ce t as noted in Item 19 <br />T <br />Printed/ ped Nom <br />Sig.11. <br />Month Day ea <br />DO NOT W�TE BELOW THIS LINE.— <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />DTSC 8022A (4/97) (Generators who submit hazardous waste for transport out-of-state, <br />EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />