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state of Califomia—Environmental Protection Agency ]'1 <br /> Form-Approved OMS No.2050-0039(Expires 9-3095) ( SCC In3tI'YCf ons OR back fti pO9C 6. Department of Toxic Substances Control <br /> P Ase print or type. Form designed for use on elite{12-pn., .ypewriter. Sacramento,California <br /> 1. Generators US EPA ID No. Manifest Document No. 2- Page 1 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federat law. <br /> WASTE MANIFEST .�. I rr F� Z ! $ of <br /> 3. Generator's Name and Mailing Addressc� . ., A State Manifest Document Number <br /> US ,� , f �'• <br /> x 9 5�43083' <br /> Ln"' 601 SOMM F� A sr <br /> a r <br /> 6 State Gnerator <br /> e 's ID <br /> II s - <br /> n STGOTON, CALM � � <br /> 4. Generator's Phone {�{}1) r37 �7'�! r ; «ti,3 <br /> 5. Transporter 1 Company Name 6- US EPA ID Number C State Transporters ID <br /> D Tran rter s Phone <br /> ASBURY T SxOr3TATI0- A 0 2 $ 2 717101316 A �'° � � t30#3 72 * <br /> JQ 7. Transporter 2 Company Name 8. US EPA ID Number E Slate Trarrsporter:s ID r ?®0 �N A l <br /> a <br /> F Transporters Phone § <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G State Facility's ID <br /> 00,F. <br /> 73co r' 1\IQ3fd?'1� 3 sr <br /> O 2000 NORTH ALAMFMA ST. H Facility's Phone <br /> 0 <br /> a <br /> CWTON,g L:A 90222 GAT $ 0 0 "� 3 S Z .4310X37,=71 1 ".; , <br /> Z 11. US DOT Description Cincluding Proper Shipping Name,Hazard Class,and ID Number) N Containers 13. Total 14. Unit <br /> ' . <br /> �a 1 No. Type Quantify Wt/Vol -I Waste Number .;� <br /> LO 3 N01% R—CRA WARSOUS WASSE, LIQUID, (OTLY WAS 22��� u <br /> y t A EPA/Other <br /> o E i1 1 T f; <br /> eco N �' re Sra ' ''� s � <br /> r <br /> N E EPA/Other <br /> .* R . <br /> 0 <br /> Ct A c. State a i" s1 r: <br /> C? TO sl <br /> R EPA/Other zp <br /> U <br /> 1— <br /> Z d, State <br /> V <br /> EPA/Other <br /> VJ <br /> Z K. Handling Codes for Wastes Listed Above , <br /> (J J. Additions!Description3 for Materials Listed Above 9 <br /> b. <br /> Uj <br /> ac XI A.E„R.G. #128 tl <br /> r c. d <br /> 15. Special Handling Instructions and Additional Information <br /> ZK' €CY PSPONSE COII TACT 24 NOU <br /> M�KL RAFPER (310) 686-3400 NUN <br /> (310) 602-9$95 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment a e fully and accurately described above by proper shipping name and are classified, <br /> V packed,marked,and labeled,and are in all respects in proper condition for transport by ighway 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 he volume and toxicity of waste generated to the degree i have determined to be <br /> p, economically practicable and that I have selected the practicable method of treatment,s oroge,or disposal currently available to me which minimizes the presets and future <br /> tn threat to human health and the environment;OR,if I am a small quantity generator, I I ave 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 /> O Printed/Typed Name r4_ Signature:s Month Day t earl <br /> '1 ..... <br /> Vk1 f .x t"t..c.+1�..i-:. •7'�.7r2 i�" h1` tl L_J. �+: _�.,.-s.. ��..r.r~:�.r`:s.-.Jv:- r's� ;VL-L%�CSL..?` t d..-� .; <br /> Z R 17. Trans orter 1 Acknowled ement of Recei t of Materials <br /> 0LLJ A Printed/Typed Name Signature r month Day Year <br /> LW 5 <br /> P i <br /> er 2 Acknowledgement of Receipt of Materials <br /> O 18. Trans ort = r <br /> u. T Printed/Typed Name Signature Month Day Year <br /> 0 E <br /> It <br /> N19. Discrepancy Indication Space <br /> a <br /> U FA <br /> Z C <br /> 1 <br /> L <br /> 1 20. Facili Owner or Operator Certification of receipt of hazardous materials covered by thi manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (9/94) :Ice: GENERATOR SENDS.THIS COPY TO DTSC WITHIN 30 DAYS, <br /> EPA 8700-22 * :,0. Box 400, Sacramento, CA 95812-0400 <br /> M <br />