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7. <br />State of Califorrio—Environmental Protection Agency <br />Form Approved 0011 No. 2050-0039 (Expires 9-30-99) <br />Please print or type. Form designed for use on elite f 12 pewriter. <br />Q <br />CIIIJz <br />1Mad <br />a <br />�a <br />V <br />Z <br />X <br />r <br />3 <br />N <br />C <br />cc <br />cc <br />N <br />c <br />C <br />a <br />LL <br />v <br />CL <br />v <br />LL <br />1k <br />Q <br />2 <br />C <br />i= <br />a <br />2 <br />LL <br />F- <br />a <br />c. <br />u <br />C9 <br />C <br />L <br />LL <br />L <br />0 <br />LL <br />LL <br />LL <br />C <br />u <br />v <br />a <br />2 <br />See Instructions on ba age 6. Department of Toxic Substances t <br />Sacramento, California <br />A DO NOT WRITE BELOW THIS LINE. <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information is the shaded areas <br />UNIFORM HAZARDOUS <br />is not required by Federal law. <br />WASTE MANIFEST <br />�CIAIL10101012151612101612 14 0 13 14 <br />aft <br />3. Generator's Name and Mailing Address <br />A. State Manifest Document Number <br />240240:3 <br />O ��ER <br />W TIN <br />4FITER <br />STOCKTON CA M16 <br />B. Stole Generator's ID <br />A. Generator's Phone ( 209 949738 <br />5. Transporter Company 6. US EPA ID Number <br />. C, State Transporter's ID [Reserved.] <br />pNaame A� �/ <br />r I <br />ASBURY ENVIRONMENTAL SERVICES C IA I D 10 2 18 12 17 17 10 13 16 <br />D. Transporter's Phone W)97444% <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID (Reserved.} <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 />D / K- EWRONIVENTAL <br />H. Facility's Phone <br />9G+1J1 EAST rOTH STREET <br />f _, J <br />LOS E ES CA GAT 0 8 10 10 13 13 6 18 11 <br />I@23)20M .. <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />I. Waste Number <br />No. <br />I Type <br />HAZARDOUS WASTE LIQUID, N.O.S, 9,, NAM, PG III <br />State 13,5 <br />i <br />EPA/Other <br />G <br />E <br />b. <br />State <br />NON RGRA HAZARDOUS WASTE SOLID ( OILY SOLIDS) <br />EPA/Other <br />E <br />R <br />NONE <br />A <br />c <br />State <br />T <br />O <br />EPA/Other <br />R <br />d. <br />State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed v/ery� � <br />K.-Handlin Codes for Wastes Listed Above <br />9 <br />b` <br />X 0 ADD STATE CODE 223 3° 161 <br />c. <br />d <br />15. Special Handling Instructions and Additional Information <br />USE PPE EMERGENCY CONTACT :CHEMTREC 1-100-424-9300 <br />NAERG#. `11A,. 171, 1`1I3. ii9 <br />�jq� <br />416..E1N,E TOR'S CERTIFICATION: I here y declare that the contents of this consignment ore fully and accurately described above by proper shipping name and are classified, packed, <br />in for transport by highway according to applicable international and national government regulations. <br />and labeled, and are in all respects proper condition <br />If 1 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 economical) <br />treatment, or disposal currently available to me which minimizes the present and future threat to human heah <br />practicable and that I (,ave selected the practicable method o storage, <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 <br />avoiloble to me and that I can afford. <br />Pred Typed Name <br />' <br />Mont Da Y <br />6 7• <br />T <br />17. Trans rter 1 Acknowledoemenflof Receipt of Materials <br />R <br />Sign ture <br />Month Day Y <br />B <br />S <br />Prin <br />d/T ped Name �� <br />P <br />Transporter 2 Acknowled ement of Recei t of Materials <br />k18. <br />T <br />Printed/Typed Name <br />Signotur <br />Month Day Y <br />E <br />R <br />Ailk <br />19. Discrepancy Indication Space <br />6F& imps �� � 1 1 r �✓ Y�.L/ <br />C <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered 6 .this manifest except as noted in Item 19. <br />YPrinted/Typed <br />Name <br />Signature <br />Month Day Y <br />A DO NOT WRITE BELOW THIS LINE. <br />