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LICENSED CONTRACTOR DECLARATION
I,hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
610005 C-12 �13IU�•
Date"'! -- u Signature of Contractor �4 ? �, V✓
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code). - P,
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:.
Carrier BTS E FUND Policy No. 09fr�1-CS���,�fl3
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. f /
Date: I' t Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
Df the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. v
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) r 4; ! ' ! Date T.0
" �.; .
.4BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB ADDRESS �J� 411. DRUM (11TIUD DE
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
vibfFf.AAN MAR1iIN
A PY,U1it1r'81~3:L"Ai1K1*1N ter R, ORADI +G
78-060 C%aML' U PADO
x'101 B0X 1036
Lk QUD3TA
1.fA Qil"WfA S_ k 92253
(760)30(;-025 3 C:5141, 49!
USE OF PERMIT
A SINVW. STRvC'Z UMS
C"Oar"�' C'%�►�'C 0WIR 'I:r�SA�� O,Xf
••�y����yy^�p ��77���p ••�g,�sqyy,� � �y w�EI�b".d'�i,�`IZ0
P.dt,Ai.ii'YR.8�.N 8ki�'E SVMMAR ,
101.000-423.000 IiAw.00
cy.
t7LW1.`tYl:.AL COMRiM1014> :E LW C`M
.5.00
�X
- - %l �i?a1 31
$0.00
oo : 'PERAM S My, NOW
941.5.00
Asir, 12 2U ,
CITY OF LAQUINTA
FINANCE DEPT.
RECEIPT
DATEs,
BY=
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION I DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O. K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int, Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover.
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
DATE: August 4, 2002.
PAGE:I
LABORATORY "PAT" ID # ; 11067
ANALYTICAL METHOD NIOSH 7400 "A"
Sample
J&H Environmental, Inc.
Flow
(1/min.)
Air Samples' Results
CLIENT NAME: Union Environmental
LABORATORY REF. #: M982112
JOB NAME: 5 1 -11 1 Desert Club Drive
CLIENT JOB NUMBER: NIA
JOB ADDRESS: La Quinta, CA
CLIENT P.O. NUMBER: N/A
Apartments 3, 2, 6 and 7
F/Sq.mm Det. Lim
Fiber/cc
Results
Fiber/cc
ANALYTICAL DATA
DATE: August 4, 2002.
PAGE:I
LABORATORY "PAT" ID # ; 11067
ANALYTICAL METHOD NIOSH 7400 "A"
Sample
Pump
No.
Flow
(1/min.)
Cassette
Type
Sample
Date
Runnin
Stan I
Time
stop
Duration
(Min.)
Volume
(Liters)
Pump Calibration
Before After
Field / Fiber
F/Sq.mm Det. Lim
Fiber/cc
Results
Fiber/cc
H/M
1&H O1
10.0
25
8/4/02
16:15
18:15
120
1200
10.0
10.0
100
2.0
2.55.
0.0022
B.D.L.
2
J&H 02
10.0
25
8/4/02
16:15
18:15
120
1200
10.0
10.0
100
1.0
1.27
0.0022
B.D.L.
3
1&1103
10.0
25-
8/4/02
16:18
18:18
120
1200 '
10.0
10.0
100
3.0
3.82
0.0022
B.D.L.
4
J&H 04
10.0
25
8/4/02
16:18
18:18
120
1200
10.0
10.0
100
1.0
1.27
0.0022
B.D.L.
5
J&H 05
10.0
25
8/4/02
16:20
18:20
120
1200
10.0
10.0
100
2.0
2.55
0.0022
B.D.L.
6
0.0
25
8/4/02
0:00
000
0
0
0.0
OA
100
0.0
0
-
N.D.
DESCRIPTIVE INFORMATION
Sample
I.D.
Sample
Type
Sample Location
Resp.
Type
Remarks U.C.L.
1
Area
Inside Work Area - Unit 3
H/M
Post Asbestos Abatement Activities (Finals)
2
Area
Inside Work Area - Unit 3
H/M
Post Asbestos Abatement Activities (Finals)
3
Area
Inside Work Area - Unit 2
H/M
Post Asbestos Abatement Activities Finals
4
Area
I Inside Work Area - Unit 2
H/i�1
Post Asbestos Abatement Activities (Finals) .
5
Area
Outside Work Area
H/M
Post Asbestos Abatement Activities (Finals)
6
Blank
Field Blank
Field Quality Control Blank
COMMENTS:
KEY TO ABBREVIATIONS
SAMPLE TYPE: PRS: Personal, PRM: Perimeter, ENV: Environmental, BGD: Background,
FC: Final Clearance, HEX: I IEPA Exhaust, AR: Area.
RESPIRATOR TYPE: HM: Half Face Negative Pressure, FF: Full Face Negative Pressure,
PAPR: Power Air Purified Respirator, SAC: Supplied Air Continuous,
SAPD: Supplied Air Pressure Demand, SCBA: Self Contained Breathing Apparatus.
Analyzed by: Brad Sullivan
♦0
O
N
CLIENT NAME: Union Environmental .
JOB NAME: 5 1 -1 I 1 Desert Club Drive
JOB ADDRESS: La Quinta, CA_
Apartments 3, 2, 6 and 7
J&H Environmental, ine.
Air Samples' Results
LABORATORY kEF. 9: M982112
CLIENT JOB NUMBER: N!A
CLIENT P.O. NUMBER : N/A
ANALYTICAL DATA
DATE: August 4, 2002.
PAGE:2
LABORATORY "PAT" ID #: 11067
ANALYTICAL METHOD NIOSH 7400 "A"
Sample
I.D.
Pump
No.
Flow
(1/min.)
Cassette
Type
Sample
Date
Running
Start
Time
Stop
Duration
(Min.)
Volume
(Liters)
Pump Calibration
Before I After
Field ! Fiber
F/Sq.mm Det. Lim
Fiber/cc
Results
Fiber/cc
1
J&H 06
10.0
25
8/4/02
16:30
18:30
120
1200
10.0
10.0
100
3.0
3.82
0.0022
B.D.L.
2
J&H 07
10.0
25
.8/4/02
16:30
18:30
120
1200
10.0
10.0
100
2.5
3.18
0.0022
B.D.L.
3
J&H 08
10.0
25,
8/4/02
16:32
18:32
120
1200
10.0
10.0
100
1.5
1.91
0.0022
B.D.L.
4
J&H 09
10.0
2.5
8!4102
16:33
18:33
120
1200
10.0
10.0
100
2.0
2.55
0.0022
B.D.L.
5
J&H 10
10.0
25
8/4/02
16:35
18:35
120
1200
10.0
10.0
100
3.0
3.82
0.0022
B.D.L.
6
0.0
25
8/4/02
0:00
0:00
0
0
0.0
0.0
100
0.0
0
-
N.D.
DESCRIPTIVE INFORMATION
Sample
I.D.
Sample
Type
Sample Location
Resp.
Type
Remarks U.C.L.
1
Area
Inside Work Area - Unit 6
H/M
Post Asbestos Abatement Activities Finals
2
Area
Inside Work Area - Unit 6
H/M
Post Asbestos Abatement Activities (Finals)
3
Area
Inside Work Area - Unit 7
H/M
Post Asbestos Abatement Activities (Finals) •
4
Area
Inside Work Area - Unit 7
H/M
Post Asbestos Abatement Activities (Finals) .
5
Area
Outside Work Area
H/M
Post Asbestos Abatement Activities (Finals)
6
Blank
Field Blank
Field Quality Control Blank
COMMENTS:
KEY TO ABBREVIATIONS
SAMPLE TYPE: PRS: Personal, PRM: Perimeter, ENV: Environmental, BGD: Background,
FC: Final Clearance, HEX: i TEPA Exhaust, AR: Area,
RESPIRATOR TYPE: HM: Half Face Negative Pressure, FF: Full Face Negative Pressure,
PAPR: Power Air Purified Respirator, SAC: Supplied Air Continuous,
SAPD: Su lied Air Pressure Demand, SOBA: Self Contained Breathing Apparatus.
Analyzed by : Brad Sullivan
O
W
CLIENT NAME : Union Environmental
JOB NAME: 78-040 Ave. La Fonda (Video Store)
JOB ADDRESS: La Quinta, CA_
J&H Environmental, Inc..
Air Samples' Results .
LABORATORY REF. #: N/A
CLIENT JOB NUMBER: N/A
CLIENT P.O. NUMBER. N/A
ANALYTICAL DATA
DATE: August 6, 2002.
PAGE: I
LABORATORY "PAT" ID #: 11067
ANALYTICAL METHOD NIOSH 7400 "A"
Sample
I.D.
Pump
No.
Flow
(1/min.)
Cassette
Type
Sample
Date
Running
Start
Time
Stop
Duration
(Min.)
Volume
(Liters)
Pump Calibration
Before After
Field / Fiber
F/Sq.mm Det, Lim
Fiber/cc
Results
Fiber/cc
I
J&H 001
10.0
25
8/6/02
16:30
18:30
120
1200
10.0
10.0
100
3.0
3.82
0.0022
B.D.L.
2
J&H 002
10.0
25
.8/6/02
16:30
18:30
120
1200
10.0
10.0
100
1.5
1.91
0.0022
B.D.L.
3
J&H 003
10.0
25'
8/6/02
16:31
18:31
120
1200
10.0
10.0
100
2.0
2.55
0.0022
B.D.L.
4
0.0
25
8/6/02
0:00
0:00
0
0
0.0
0.0
100
0.0
0
T_77
N.D.
DESCRIPTIVE INFORMATION
Sample
I.D.
Sample
Tpe
Sample Location'
Resp.
Type
U.C.L.
I
Area
Inside Work Atea
H/M
-Rernarks
Post Asbestos Abatement Activities (Finals)
2
Area
Inside Work Area
H/M
Post Asbestos Abatement Activities (Finals)
3
Area
Outside Work Area
I H/M
jPost Asbestos Abatement Activities Finals
4
Blank
I Field Blank
I
IField Quality Control Blank
COMMENTS:
KEY TO ABBREVIATIONS
SAMPLE TYPE: PRS: Personal, PRM: Perimeter, ENV: Environmental, BGD: Background,
FC: Final Clearance, HEX: I]EPA Exhaust, AR: Area.
RESPIRATOR TYPE: HM: Hal Face Negative Pressure, FF: Full Face Negative Pressure,
PAPR: Power Air Purified Respirator, SAC: Supplied Air Continuous, -
SAPD: Supplied Air Pressure Demand, SCBA: Self Contained Breathing Apparatus.
Analyzed by : Brad Sullivan
v
0
4
...U. 111.r
Form Approved OMB No. W50-0039 [Expires 9-30.99) See Instructioniaon back of page 6. Department of Toxic Substances Control
Please print or type. Form designed for use on elite (12 pitch) typewriter. r Sacramento, California
DO NOT WRITE BELOW THIS LINE.
DTSC 8022A (1/99)
EPA 8700-22 Yrllerr GFIdI-PAIOR RFIAINS
UNIFORM HAZARDOUS
I. Generator's US EPA ID No. Manifest Document No.
2. Page 1
Information in the shaded areas
C A C 0 0 2 5 '4 8 3 f
is not required by Federal law.
WASTE MANIFEST
,5
6 ' � � �
� of �
3. Generator's Name and Mailing Address SITE:
A. State Manifest Document Number M ^o H
yVd
J
Marvin Humus 70804 Call, l,a Fonda
LJ
90yCy..alle Estado #201 La Ouint; 1, CA
B. Stale Generator's ID
TT7a8—(0(���,,�,,
aon ', CA 9225310 — 256-7
5. Transporter 1 Company Name 6. US EPA ID Number
C. State Transporter's ID [Reserved.) 3201
D. Transporter's Phone J-7 14) 375-7749
7. Transporter 2 Company Name 8. US EPA ID Number
E. State Transporter's ID [Reserved.]
F. Transporter's Phone
9. Designated Facility NgmeAar S'tq.�d 41s t" LtlTi���illl 10. US EPA ID Number
126999
G. Stat Fa;' ID
n S u p 1 y
Y .% r!p 9 9
1'.1aghway 95 Mile. Post 1211.
H. Facility's Phone
AZ 853 r-. ( .$ 1
n
X28 �1b-1.x53
11. US DOT Description (including Proper Shipping Nome, Hazard Class, and ID Number)
12• Containers
13. Total
Quantity
14. Unit
Wt/Vol
1. Waste Number
No.
Type
a.
Stale
151
E
R.Q. Waw 11 ybeg aur y NA 22.12 JIG UI
0
1
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EPA/Other
N
b. `
State
E
\
EPA/Other
R
TC.
�.
State
O
EPA/01her
R
d.
Slate
EPA/Other
J:.Additional Descriptions for Materials Listed Above -
K. Handling Codes for Wastes Listed Above
b.
ADEQ Abr cwlity VVt 3033 N. Central Ave,
C.
5012.'. )ohn Willing
15. Special Handling Instructions and Additional Information
IfIvxximts wade. M &A l3twk bW cw C%+1mw &a. 11lwid Bre0b7Jig (Rist.
ER .=,y codas: Fmigemy 1w.
kart' F .58W.s QW40171. PROP L . NO. 11.11 >,6fNK771
16. GENERATOR'S CERTIFICATION- I hereby declare that the contents of this consignment are fully and accurately described above 6y per shipping name and are classified, packed,
labeled, for
marked, and and are in all respects in proper condition transport by highway according to applicable international and nalional government regulations.
IFIam a large quonliy 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 economicallyy
and that I have selected the method of treatment, storage, or disposal to the future to human heallh
practicable Practicable currently available me which rhinimizes present and threat
and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste genera)ibn and select the best waste management method that is
available to me and that I can afford. ....-- –
rinted/Ty Nssme j'
/ /.•
,r1 �'l E•'1 c<..'f�,_.. • ',
SignaturA'
• _ - ._`./�:, —, �/. /
Month Day Year
r;% .�:
f^� ; �/
dam•--•
RT
17. Transporter 1 Acknowledgement of Receipt of Materials
p
Pr' ted/Typed Name !t
igna� , i
�\
o�Da Years
r
P
0
18. Transporter 2 Acknowledgement of Receipt of Materials
TPrinted/Typed
Name
Signature
Month Day Year
E
R
_
19. Discrepancy Indication Space
F
A
C
L
t
[
20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19.
T
Prinled/Typed Name
Signature
Month Day Year
Y
DO NOT WRITE BELOW THIS LINE.
DTSC 8022A (1/99)
EPA 8700-22 Yrllerr GFIdI-PAIOR RFIAINS
• 9.30- See Instcudfion F n back of page 6.
Form Approved OMB No. 2050-0039 (Eibire& 9.30.99) i• I � P 9 Department of Toxic Substances Control
Please print or type. Form designed for use on elite (I 2 -pitch) typewriter. Sacramento, California
DO NOT WRITE BELOW THIS LINE.
,DTSC 8022A (1'/99) Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS.
EPP, 8700-22 To: P.O. Box 400, Sacramento, CA 95812-0400
UNIFORM HAZARDOUS
1. Generator's US EPA ID No. Manifest Document No.
2. Page 1
1 1
Information in the shaded areas
is not required by Federal law.
WASTE MANIFEST
CAC 0 0 2 5 5 4 8 1 3 6 7 2 8 9
of
3. Generator's Name and Mailing Address SITE:
A. State Manifest Document Number
t 1 *21867289
Marvin Homes
78-080 Calle Estado #201 51111 Desert Club Dr.
•
8•�jateGenerator's ID
j�
Z� Q>!:inta, CA
Ren9VAaka t I CA 12253760 771-2967
S. Transporter 1 Company Name 6. US EPA ID Number
C. State Transporter's ID [Reserved.j 3296
g & R Sav1Ce5 Jnc 1
D. Transporter'& Phone 14 375-7748
7. Transporter 2 Company Name B. US EPA ID Number
E. State Transporters ID [Reserved.)
F. Transporter', Phone -
9. I)Cgnated Facility Na Pe c1 �T 7 _t.lL:tt 10. US EPA ID Number
LL
G% Stot�FartCID9 5 0 8 2 3 1 1 1
e1Posrtt 128.
26t119��,i+.g}^�.y.�+.p+ 9L5 Mile
H. Facility d Phone
P'""'�
Parker, AZ 85344°
(928) 916-1253
11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number)
12. Containers
13. Total
Quantity
14. Unit
Wt/Vol
1. Waste Number
No.
Type
a.
State
C 1
J
�
/s
NA 2212, PG 111EPA/Other
Asbestos,1
R.Q. Waste 9
E
,
N
b.
State ..
E
EPA/Other
R
T
C.
State
O
EPA/Other ,
R
.,d'
State
EPA/Other
J. :Additional Descriptions for Materials Listed Above • t , s ' ;
K. Handling Codes for Wastes listed Above
y
'Y'_JYJ
in fjli" itll� JMW �', -
t
s ..
r ADEQ Air Quatttty Det 3033 N 1 Ava
._
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AZ 85012 Anton: Jdm Mardi'' 'i
t r
15! Special Handling Inst_gty:V uaCy por du pAvoid Bm g
EmaVmy no.
DOT P SK*.5 (3" 171 PROFRZ NO. LP66M771
E.P.A. RD&n 1X 21865 L Capiky Drive, Dim Bff, Ca 91765
16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurate)y described above by proper shipping name and are classified, packed,
marked, and labeled, in in For transport by highway
and are all respects proper condition according to applicable international and national government regulations.
If I am a large quantiy generator, 1 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 economicallyy
I have disposal
practicable and that selected the practicable method of treatment, storage, or currently available fo me which minimizes the present and future threat to human heolth
and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation a d select the best waste management method that is
available to me and that I can afford.
Printed/Typ d Na a
Signature - /
Month Day Year
Cit
T
17. Trans orter 1 Acknpv4edgem4nt of Receipt of Materials LO
R
A
R
P' /Typed •
Sign u
M
on h ay Year
S
P
v✓ " "
lo
I, A
0
_
18. Transporter 2 Acknowledgement of Receipt of Materials
TPrinted/Typed
Name
Signature
Month Day Year
E
R
19. Discrepancy Indication Space
F
A
C
I
l
20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19.
T
Printed/Typed Name
Signature
Month Day Year
Y
DO NOT WRITE BELOW THIS LINE.
,DTSC 8022A (1'/99) Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS.
EPP, 8700-22 To: P.O. Box 400, Sacramento, CA 95812-0400
�Iwu u• ..••.�•„u u.0 ..omni.....wawa i.dui.Ly I
Form Approved OM8 No. 2050-0039 (Expires 9.30-99) See Instructions on back of page 6. Department of Toxic Substances Control
Please print or type. Form designer/ /or use on elite (12 -pitch) typewriter. W , '- Sacramento, California
DO NOT WRITE BELOW THIS LINE.
DTSC 8022A (1/99)
EPA 8700-22 YpIl'-- (WNPRAIOP R[IAIIdS
UNIFORM HAZARDOUS
1. Generator's US EPA ID No. Manifest Document No.
ICIAICIOIO1215151418111316of
2. Page 1
Information in the shaded areas
is not required by Federal law.
WASTE MANIFEST
3. Generator's Name and Mailing Address SITE:
A. State Manifest Documjnt NuTbor p� .y �y
F9
Marvin Rcmes
KSI. 6r
E ad[�j� #201 51111 Desert Club Dr.
B. State Generator's ID
ACa11e
4. GenBfa cr�on1' (CA760 .L25J LZ QuiTlta, CA
F
771-2567
5. Transporter 1 Company Name 6. US EPA ID Number
C. State Transporter's ID [Reserved.]
D. Transporter's Phone
y y
�8.
7. Transporter 2 Company Name US EPA ID Number
E. State Transporter's ID (Reserved.]
F. Transporter's Phone
9. Designated Facility Ngnf pndy5' er d�rpl� 1l� i ,. j� yi 10. US EPA ID Number
G. Stat F �ID9 G 0 9 '2 I .9 1
•Y (9 J .3
C
26999, Ifi bway 95 Mgt Pcxit 128,
Ph
H. Facility's one
PftTkem AZ 8. 344 C I
(w)8) 916-.125_
11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number)
12. Containers
13. Total
Quantity
14. Unit
WI/Vol
1. Waste Number
No.
Type
o.
State
151
R. . 'Wasc$ Asbestos, 9, NA 22 2,,11Ca .B.
t� 1
, ��
`r
EPA/Other
Nb.
State
RF:
EPA/Other
T
`V
State
0
R
EPA/Other
d.
State
EPA/Other
1: Additional Descriptions for Materials Listed Above
K. Handling Codes for Wastes Listed Above
mwAcdId
a. b.
A DEQ An QW4 D%* 3133 N. Ca" .Am
C.
d.
AZ 8"12 Atim: Iaho A Ming
15. Special Handling Instr�cjions ark Additions Infot�ation
Xlit7�p BHF l<K► K4 fJly* i> Oi Oa1l= &wL /1ivoii T§vi6ib.EP% chmL
FIMget y 0mad: AC.Y2t jl IIU.
DOT? 58M.5 G oido 171 PR.ORL I..: NO. 1,P66( ":771
&P.A.1Ro '. ' I.X 21865 E. o . Dfli �:,1:1)fukumd P: - Y" Cq 91765
16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above byproper shipping name and are classified, packed,
marked, and labeled, and are in all respects in proper condition for transport by highway according' to applicable international and notional government regulations.
If I am a large quantify generator, I certify that I have a program in place to reduce the volume and foxict of waste generated to the degree I have determined to be economically
practicable and that I have selected the practicable method of treatment, storage, or disposal currently avoilable to me which minimizes the present and future threat to human health
and the environment; OR, if I am a small quantity generator, I hove made a good faith effort to minimize my waste generation and select the best waste management method that is
available to me and that 1 can afford.
Printed/Typed Name
'A
Si nature
.� .+� •�,�i•"°'
/moo, \.y
Month Day Year
_-
.,%i
1 •,-r
�1
R17.
Trans orfer 1 Acknowledgement of Recei t of Materials
A
PriQlfd/Typed No a
gnat.
Montt -Pay Year
g
—rT. Transporter I Acknowledgement oF Receipt of Materials -i
R
T
Printed/Typed Name
Signature
Month Day Year
E
R
19. Discrepancy Indication Space
F
A
C
L
1
20. Facility Owner or Operator Certification of receipt of hazardous materials
covered by this manifest except as noted in Item 19.
T
Printed/Typed Name
Signature
Month Day Year
Y
DO NOT WRITE BELOW THIS LINE.
DTSC 8022A (1/99)
EPA 8700-22 YpIl'-- (WNPRAIOP R[IAIIdS