HomeMy WebLinkAboutSLOUNIFLOW_FS1 Admin iRC3926i Color_1475_001 rpt 3 of 3PR0JECT SWI4ARY REP0RT for ATOLL HOLDING, LLC <
1150 Laurel Ln, San Luis 0bispo. CA 93401 <-> APN 004-962-018
T*suE oF ColffEltrrs
COVER LETTER
pt jr{.+
REGULATORY PERMITS
ASBESTOS & LBP REPORT
SITE HEALTH & SAFETY PLAN
}IASTE }IATER ANALYSIS
SOIL ANALYSIS REPORT
COIiIPACTION TESTING REPORT
REGULATORY INSPECTION REPORTS
TAI,IK DISPOSAL REPORT
HAZARDOUS }IASTE MANIFESTS I
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PROJECT SUMMARY REPORT for ATOLL HOLDING, LLC < ' > Project Ns' 2A18-27
1150 Laurel Ln, San Luis Obispo, CA 93401 <-> APN 004-962-018
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>>> REGULATORY II{SPECTION REPORTS >>
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I City of San Luis Obispo
Building & Safety Division
Permlt Number DEMO-1817-201r
Work Glass Building
ProJect Descrlpll OEMO OF 2 COMMERCIAL STRUCTURES
ProlectAddr€ss 1150 Laurel Ln, San LuisObispo, cA 93401
FOR ,ilSPECNON9 CALL 805.787.778A ONE DAY PR'ORTO REQUESTED DATE
AND PNOWDE PERM/T NUMBER AND ADDRESS
FIA'ALS MU$T BE
PRIARTA AWLD'NG FINAL
lnspection Record
Date 9l17n01B
lnspector
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T-Bsr / Swpended CeilingFqrtdation Water+roofi ng and Drainage
Erderior Lath & FlashingRetaining Wsll/ Masonry Reinforcament
lnlerior LathLlsht, Sisn, Oeck, Trellis Footlns
Showsr Pan LinerUter Gmund
Gas PressureTsstFoms, ExGvallon, Reinforcdment, Rebar
Dryilall NaillngStomwaterBMPS
lnsulationRough GEding / Pad C€rlifica$on
lnspectorDateSURFACE COVERINCSlnspectorDalsFOUNDATION
Temporary Power Pole
Post-Ciiiislrudion MeasoresIrash.rO6Ms,
GEding & OralnageSediment Oisdlargs / Track€ul
Slom oralnStabllizad EnlEne
S[e Wa[ OralnageSlop€ Stabllizauon
Sitawall RginlorcementGrading i Grubbing Site
Site Wall FootlnoDust Conlrol
O€dq Trsllis, Ught, Shn FoolingsConcrole, Paint, Plasler Washouls
Elsld€l ConduilsSilt Fsnce
Gas Pidno & Pressure TestFiber Rolls
Waler SsMceSWPPP / WPCP Plans On Site
Sfls Latsral E Baclffits ValvelnspectorDateSTORMWATER
DateSITE WORK
Windoffi
Rough Mechanical
Rough Fire Sprlnklers
Ga3 Piping & Pressurs Test
Rough Plumbing / OWV Test
Rough ElecNrical
Rough Fming
Floor Nailing
: f81L-lt\lt( llKVtuirt()lna,Shan Wsll Nailing
lnspectorDateOEPART$ETff FINALSRoot Nailing / Truss Layout
Post-Cotrlrucuon Moass
lnspectorDateROUGH INSPECTIONS
Gradng E Orainags
Smoko / Garton Monodde AlatmsUnd€rflffi lnsulalio
Gas MeterRele€SeFloor Fmmlng
SIalrs, Ha]daails & Guard RailsMtrhani€l Ducls
Accessib{lityElectrlcal'Condults
Firo SprinklerTrim & TestGas Piping
Finlsh Mechani€l & Ouct TeslingWater Piping
Flnish ElectdcalSlab Rslnftrcament & MoistuG ganisr
Finish PlumbirEDWV Pidng and Test
DatePRE.FINALlnspectotDateUNDERFLOOR' SLAB
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I\-FINALAPPROVAL Date
D
lnspector
Partiol lnspections Noted Below
_,-.]i b'I t' tl*sdf,d'*']
CONSTRUCTION & DEMOLITION RECYCLII|C itLef,f and DISPOSAL REpORT
City of San Luis Oblspo Utilltles Department r 879 Morro Shee( San Luls Obispq CA 9340,1 r 805-?O,l,Z?t6. SEE SIDE TWO FOR STEP BY STEP INSTRUCTIONS
h()*l?tT'7* ltr
Usirig a Certified ltecycling Company excluslvely?
Which one?
icant's -6-2-ol?
a
Estlmated Tons of Disposed Waste to Landfill(35%)
Estimated Tons to be Recycled & Reueed (65%)
(see chaflon hackof ttb lormforcalculatlon)
Estimated Total Constructlon Waste (recycled & dlsposed)
BEFORE CON$TRUCTION
ronts
?e
1,go
tz Fill out of all
AFTER
Tons- ALL RECEPIII AREasa-5;_
c/7
Percentago of Materlals Recycled & Roused:
lnclude a copy of thls completed form wlth your bulldlng plan eubmlttal.
+
-YoI
Trash/Landfill
On-Slte Reuse
Off-$lte Recycle
TOTAL:
'lleftsu\ otn*t
Substantial Comoliance:
GoalAchievedl J
Goal Not Achievul:
Rovlowed/Approved bv:fiAkPonalty Paid;
CIu", ff)lffili{U
$ection 4i For OftbeUse
State rcgulcrllons. Foq yout eonventencq
Colleetlon Companles is in. that ottaclrecl
lisr of Cadfied ftecndbq
CONIPLETING THIS FO
Please tud tltls foml cnrcfully The goal ts
lnve recXcled d mlniwan of 65% af
fumish n drop-box and pwvtde you with n
to completethlsfomu
,tr{tffiffi& Completely fill out
2 (ieverse side sf this form,)'
,,.Ws Project Completiort
l. Gnther recolpts listing tonnage
prnject si0e, Recelph must list
dlsposed,
2, Fill out Section 3 on reverse siile
availtble for sl gn-off.
-
rl nl
'
F'ROGRAM
cleaily doewnenl ,that !s1s
and denp matefials, pet
Tlrcse conqtanles qtn
of tonnngeyou msy use
I and $er:tion
ont s€ction 2 - Une ths
$ign-Off
nll mrteriab that left the
as recycled or
actual tonnnge,
879,Morrofor rign-off
that sorneone will be
$lngle Famlly Resldontlal
Additlon
Dernofitlon. Neur Construction
Remodel
Example:
$q. footage of profect x tons = Estlmated Tone
. Construction Wnste Estlmntlon chnrt sldo of thls pnga) Choose
thc type of profoct and multlply tlto totts
squnre fect of the pluf ect to estimlte the
squalc foot tinres the
tonnage to he geucmtxl,
Ssctlon 2 ohoulcl ltst 65% of the total ns
shoultl bc llsted ns dlsposed. Thlr is ail
The rsmnlnlng 35o/o
ffifiM& CarefullY readr sign
statemonts:
only.
date tlre helow
Gonstruction Waete Estimafion
(recycllng + trash combined)
Tyne of Prolcct Ab6i6r. WasteiGenerated
Commerclal
Addlllon
Demolition
Netv Uonshuction
Tenant lmprovement
Multl-Famlly Resldeirtlal
Additlon
Demofitlon
New Conetructlon
Remodel
sqft
8qft
sqft
eq ft
p6r
per
.per'pdr
,011 tons per sq ft
.025 tonS per sq ft
,008 tons'per sq ft
.011 tons qer sq ft
.024 tons
.031 tons
.004 fons
.005 tons
,018 tonsper sq ft
,025 tons per sq ft
,004 tons per sq ft
,023 tons per sq ft
Construction Wasto Management Wsrksheet
*:o
" ." csw".Ss.+Y")" A**-*ft1
Y"1': ., ?*l= ?osrq! *:o,ttls'r-
! qtMlirrih tdle{rr.s rre!6!6rr'nro#s
Misc. Recycling
Mixed Recyclables
Drnusll
Gardboard
Concrete and Asphalt ?Ffl*x Fs.t*tt
3.
rT
KRITZ EXCAVATINC U.IEIGHT,IASTER'5 CEBIIFICA}E OF II'EIGHI AND MEASURE.
THIS lS TO CERTIFy that lhe toltovring descdbe.l commodity
eJag weighdd measur5d. ar counted by a vleighmaste{, vjhtse
signalur€ b on lhis certificate; who !s a recogni?ed autbority ol
accuracy, as f?rescfihdd by chapter 7 {comfnencing willi seclion
1?700) rl Oivision 5 of lhe Galilomio Buslness and Prblessions
86de. administered by tlra Division o! Measurement SlaodanJs
ol the Calilornia Oelrartrnenl ot Food and Agril)ullu.6,
KflITZ EXCAVATING & TBUCKING, IT.!C.
& TRUCKINC
415 Volpi Ysabel fid.
Faso Bohles, CA 93446
Phone (805| 239:2686
INC.
c,ll.T#171ori - 8E dsFARO15.7936d9
TR Litr/No
Tag Num-net
*"-bt],J\61
E8t
7 06
I,IATEFI4L
i,t#t'*n11o
Signalore gt Wetghmasler
-
tsack lo
sf
i'fiI*"n$t$",,floltr..*+e,-r* ' :]-52;fi9
COr{S{Gt'lEE AoDPESS .ft
CONSIGNOB
wlro orvnec ljat'l.
fiFlJlfl5'ff,1:ltouo",r tt jis t4g ! 1La
5af
otsPATcr.l
TIt,IE
I'IETCHARGFABLE
TIiIE
BEASON FOFI NI'N€. OTHEF FE}dANKS
UNDFRI-YIN6 CABFIFg
S{GNATURE
sERvlcE FEEwllu ge inngeeo tp PAYMENT ls Nor FECEIvED BEFoRE 20 DAYs AFIER
DELIVEFY OATE.
gONSICHEE AGREESTO PAY ANY LEGAL FEES FOR COLLECTISH OF OELINOUEI.IT ACCOUNT.
wE r.r*rE. oeuvgHtEs tNstoE cuRB AND oN Lor ar cuslotllEB's FlsK oNLY AND AccEPT No
RESPONSIBIUTY FOB DAIiIAGE FESULIING FROlrsUcH DEUVERY'
WHITE - ORIGINAL CANARY - BILLING PINX - OUPLICATE GOLO - DELIVERY
oare {- ,b -tA
kz - Rlte Pet Ton cr Ysd
Fm Torr or Yard
HDlJtlI RJla
00wN
IIME51il?*"s/r
TRUCK
z{
c,tJ @
/aftqI16 0f9t'
7#7soilqI'137b a8zr
UI{LOADITIGArrive - . D8par!
LOAOINGArriv€ Eepart
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rnvv.vsr auvrv vr I rrlurv9 vt 9lt/ rtyg
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Cold Canyon Lendfill
Weighed at:
COLD CANVON
2268 Carpenter Canyon Rd.
San Luis 0bispo, CA 93401
Deputy: Anna Lopez
Deposit: Anna Lopez
BILL T0: 343845
I{RITZ IRUCKING
415 VOLPI YSABEL
PASO ROBLES CA 93446
HAULER: Cash Customer
Velricle I0: UNLISTEO
Referencel LAUREL LN0rid: BURIED
JOB: r PACIFIC PETR0LIUI''i
Fre
Ori gi n:
DATE IN:
OATE OUT:
9AN LUIS OBISPO CITY COHI.{g9/78/2413 TII'IE IN: 09;25:tB
09/18/2078 TIME OUT: 09:47:52
LB
LB
tB
INB0UND TICKEI Nunber: 02-00193375
I'IANUAL GR0SS nT. 47940
MANUAL TARE }II. 34760
NET WEIGHT 13180
Oty De*cniption
6.59 GARBAGE to Burled
Amount
504.25
t
t TICKET AHOUNT:.504.25
.*;)
-7*.
!{EIGHHASTEf, CERTIFICATE :
THIS IS T0 CERTIFV that the following
descnibed conmodity was weighed,
measured, or counted by a weighmasten,
tlhose signature is on this sertif icate,
tltho is a recognized authorlty of
accuracy, as prescribed by Chapter'7
(commencing with Section 12700) of
0ivision 5 of the Californla Bus:lness
and Pnofessions Code), administered by
the Division of Measursment Standands'
of the California Depantnent of Food
and Agriculture.
Ill'^i:-lg^':i: i IL:13:,,lhl:. P?1, 100
t
10t
nedlcal wnri
.r:::a
Co il ;::nyon Landtlll
Ho' 1i1:1rJ 31'
l0t"i! ,:ANYQN
?:ll!:l .:rrpgnter Canyon R,J.
gorr i-rlis 0bispo,'CA 99401
Jep',tty: trx,,ile l]
3It-;. T0: iirl3:;16
I{RIT:: -!l t*l(IN0
415 Y{:'L.p VSASEL
PASI ftil8j i:S eA $4.16
iAUIlR: {l:rsir Customer
Vehlcls ID: Jlll-ISTED .lefarenepr L.I,UREL LNirl d: il IRIF0
lCI4i'IENT;: ll?it'l0
x]-,r-&F--7
3ri:lin: $rtN I-UIS OBISPO CITY ,l0l'll'l
)ATli IN: ly:l/ "t12018 TIHE IN: 10:06:26
IATE oUT: r.dt/r8/2018 TIi{E 0UT: .10105:26
INBiUNO "::f:(t:f Numben: 0?;00193407
t4 t,EJAt. .0R0SS t{T. d0420 Lg
tlAlJtJrlr. TARE tT. '32800 LB,
NIi' ilI:TGHT 7620 LB
0t/ &'i:i:r t)tion Amount
3,81 GAl,.ih\,.ili tii Buried 291,50
13{:liE' Al,l0UNT: 291,50
ilEI jiHt'lASl Ef i ii ]fITIFI.GAIEI
THI; IS f0 i:il::fIFV that ths fol lowing
desr:ri beij ixn:r':dltil $,a€ t{ei ghsd ;
neaiured, r$' ;r,)unt6d by a cyeigh{ragtsr.
'rho r *iqnir':i"r"e i s,. oR'thi s cept i f,i cats,
rrho lg a'r'r$:oini?ed authorlty o'f
scuiiraoy, ,si; 1'1:oscnibed by Qhapter 7
(co,Rtlgnsintl n tb Section 12700) of
Xlvl+l,on $ $f the Callfonnla Business
and Prof esri' pr r.: Code) ; adminl stered by
ihe Divlsrixr'if Fleasun€ment Stildalds*.ttre Cal ''onria'OeDartnent of Food
ffi ;* -,,r-,on jr,f-Prr,r*n
,rilltrilJ[llurqlli[H[,
*r Classification Tickst **
PURCHASE IICKET
RC 14559SA Recycling LLC
5815 Stockdale Road
Paso Robles, CA S3446
{805) 22?-r0S0
Ticket * IXDEBY
Vehicle ID: 984?707
Ref No: TKCA9B47707
Purchased From: H0l'1A00
HD I,IAITHEIIS DE}IOLiTION
P0 80x re4ffi
FRESNo, CA 93778
Traderr Kevin D. Jackson
Date: 09/18/18
Ship Date: 0S/18/18
a {aF "-J-_,
Liosnse/lD No: t33?28:ll (CA]
0ross Tare* :' 'Nat Adj Pd 9lt41500a 32560a 8s40 -i00 8840l{EIcHTi
RECTIVED A$: 1250 *1 Unpr:epared
INSPECTED AS:
HATERIAL
CONIANINATED ?IITH:
INSPECTED BY:
Deputy Signature
Sustomer Signature
SA Recycl
Gross l{sht Date/Time 09118118 15:
Tars H0ht Date/Tlme 09/i8/18 16:
equioment
I'heieby
fol lowing
to wear personal protective
i--(lnltlat nerE
\
\
It-
{lt-
IL
ilrlililr|lllilrilililr[lril
gloves
r'
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ilt illlililIIilIilrilililllr
Ticket # TXDEBL
x* Classification Ticket *r
PURCHASE TICI{ET
SA Recvclinq LLC
5at5 StockdEle RoaO
Paso Roblesi CA S3446
(805) 227-10s0
Ticket * TXDEBL
Vehicie ID: HD HATTHEI{S
Ref No: TKCASB47707
Purchased From: HDI'iAOO
HD I'IATTHE}IS DE}IOLITION
P0 Box 12483
FRESN0, CA 93778
Trader: Kevin D. Jackson
Supplier Shipment * 1250
Date: 09/18/18
Ship Date; 0S/18/18
License/lD No: E3372812 (CA.l
RC 14559
t{EIGHT:
RECEIVE0 ASr 1250 *1 Unprepared
Gross Tare Net Adj Pd41880a 32720a 9160 0 9l
!rt
60
INSPECTED A$:
HATERIAL
CONTA}IINATED }IITH:
INSPECTED BY:
Sross l,{sht Date/Time 09/18/18 11:58
Tare l{sht Date/Tine 09/18/18 i2:05
Ticket Comment: 1150 LAUREL LANE, SAN LUIS 0BI8P0, CA
Deputy Signature
Customer Signature
LLC to wear personal protective
t-
SA
tn
that
glasses,gloves
I
i-
FAGIFIG
FETROLEUTIII
CORPORAT'ON
p"o. Box z04s . orcutt cAga4st . Tel: (805) szs-1941, Fax: (B0s) 9zg48g4
4il5S2
*,u..3i-U ^_* ."" LB
t-
t-
TNUCK {
NAME OF
U}TOERLYING CAFFIER
CONSIGNOR;
CONSIGNEE:
wHo
F,O. furs
SISNATURE
t-
DEBTOFIT
POINT OF ORIGIN:
DESTINATION:
o
.1
1
5.
6.
L
10.
!1
LOCATION
REPOBTEO
TYPE OF
FOUIPMENT
t
TOIAL
TIME
Hf,S,.
MIN,
HIl$
.MIN.
Hgs
Mll\,
i^A t-.c-\ )o A JS;l\& TRUCK
lrlt8t{)lr.tqnFtgrat:llt'f6jll sE ia to""fra..Jiri ?cR coste€*#{ on oturaouEr.t
E {]}ff, lf 4Ht [q l %t€ (r anFHr]€(
F1{r D-r[ ,N.:C{.atflS
BO\'\'NTIME
CT-IARGEg
UNLMES COMMISSION REOUIRES P.*YIIiIEIIIT FOR THESE CI{ARGES ilOT LATER
THATTI THE NFTEEFITH OF TI{E TIIOHTH FOLLOWIHG DATE OF THIS EILL
nDrr'llir'lt .ltgT.nrt*gl"! *fV I} $ c
FOFI OFFICE USE ONLY
IID,CDr{ouRty
RATE
g
ENERGY SURCHARGF
AXLES
OF
oENO'NG
TOTAL
ENVINONMENTAL FEE
Sqlni Tax;
a{.*r14 rn:\ *l"-'3 xcrl-L+r
1s;, lo']9n \1*tfft
{rLlluln
?.H.so73c{tllfirFen
1 t:10rt l-0rn 1<
6 "rq3s zqTc-{{qbc{,zr4af
1't.-'j-I
^1.rltjlr]fliin l: i":
r,i ful"{1i.,1.:'11
l.lt t;
l,{_)Ai_!lr.l{l:I llIt-flAl:ii'li'l {li{{[T i{O{ln
: I Llll la(r,
;j{;lil{r: r ll:
i.iii-.{,::.Ai-ii.il'r.tr. llr-.l,.Al;il ,itlliiirr- !-rl i:iri.;'''f,ij\ ' iljlrr 'ii-it..i i,fif\r i i.i,liltJl : i'
i-tirli- .1,.:riiF:l i.T_ r}
i 'i!.I l ;,r;'rr.]Jf'lil
t [,t{- 4t:1 u 1i]i il4l: lrll.lll:;l I
l :r,. i t:l.ii'..1il
Al.l. li!t\lrii.li,l' l.rr rll r "{ ili:
i,i i 'ir,.i,j r i\.:.i ilf'i ji.ji"'ii ' '-..i:i: I i..trr; i
r': l'l,4 i.tr;i-., ri.it i'i ai ,''
SIGNATURE
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rtll Your Aggr6gtt. i{rrd*
Rscl,ct€d fod t{n$rto,
TROE$ii RgcYctl!'lc, rl'lc. DBA ROXSAND
2280 llutl'rn Road - Nipomo CA 93444
Phcrne; 805-35? -?284
Fax: 805-929-1196
www. roxsand. net
r
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g/18/2018 li:22:48 *1M
Iicket #: 2]-'7391
ACCOUNII MM,IE: 1OO?61 HCI F{jqTTHEI/IIS DBMOLITION S E:(CAVAT
HAtr,ER bInUE: 100356 PACIFIC PETROLEUM CORF
TRUCK #: FPC-351
PO *: 11.50 IAUF.AL LANE
JOB ADDRESS:
rTOB INFO:
lfeighrnacter: $ara Morris
Driver's Signatura;4*'Z--4
i.-it:i*rip r-i a.lorra.:1
t'laterial:
2T?5 - 2L'15 DIRTY COHERETT W/RE.BAR
Grosg: fare: Nst:
?60s0 tb 2?0s0 lb 49000 tb
Cusulative: 0.O0tons
Net:
24.50. Ln
liElr.inv.AgTER'S |JEBTIFICATE Tlil{i IS ffl CERTI['Y.thai: che folLowinrl
a**iiinuo carnmsdir.y $as {eiqhed, measured, sr,tounted hy a
weighmas.e.. ,,h.+** signat.,:r+r ie oi.l thie eertificlrte'; .t'hi: is a
.-",lsri zecl auLhrrri ty c,f accuracy, as presc{Ibed by chapher'
i-i"i"*un*.lng wirh bectton t??00i ol Divtsisn i of rne
California guejnese and Professions eode, a-drnlnlsr€!ed
by Lhe D11r1$1.tn or yleesurerne:1[ $t'andards sf lrte
Catitornia 0epartnent sf 'Fcod 31161 flrlrlcul"ture'
br--
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It*ft Yosr A$grcgrta l{scdr
*eqckd ant Ntlarel
Grose: Eare: ,Net:
s4640 lb 34440 Lb 50200 tb
Cqrulative: 0'O0Tons
TF.SESH RECYCLING, rNC. Dee RCXSRNO
2280 Hullon Road - Nipomo CA 934{4
Phone: 805-357-2288
Fax: 805-929-1196
\./ww. roxsaild.net
Net:
25.,10 Ln
9lLt3f20t8 1:24:40 PMficket #: 2774A3
&CCOUIIT NAI{E: 1.007 61
HAULER trAME: 100356 PACIFIC P$TROLEUM COF,P
fRUCK $: PPC-451
PO *:
.IOB }DDAASS:
.IOB fNFO:
Weighmaeter: Sara Morris
Driver's gignature:
tri4r r r*q !<-itr-tt .i
l'tat€rial:
2180 - 2180 OVERSTUED CONCRETE RUBBLE
T.IEIGHILCSTSR':J €ERI-]FIf,A?E TI{IS IS T9 CERTIFY thAt Ihe f*[TOT+iNg
described r:omrnoclit y uras weighed, measuredr or countecl by a
weigtrnaster, whose signature i-q orr this certiflcate,'whn is a
recoEnized autharity of accura'cy, ari pregerlbed by r:hapEer
? {commcnci.og with Secrion LZ?C0) ot D!r'isi+n lr of tlre
CaLifornia Busi:$ess and Profet;ilons Code, admqnisteted
by the Divlsian af i,leasure*ent Standards (}t rtre
talifcrnia Depart!ne:'lt af Food ;nd ltgrir:u!ture.
*
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All ?ol'r
^Btrcgrto
llrcdr
Rccyslad and Niirrrel
TROESH RECYCLINGI ThIC- DB]T' ROXSAND
aASO ltutton Road - I'lipomo CA 93444
Phone : 805-35? -7288
Fax: &$5'97.8-1L96
www, roxsand. net
9lL8/?ALB 3:22:30 PM
tricket #: 2L141"0
ACCOUNT
HAI.,LER
TRUCK #:
Po f :
rtOB ADDRESSI
iIOB II{FQ:
I$eigl'rmaeter : Sara l-lorris
Drivsr's Sigrrature:
NAI'{E: 100-?61 HD MATTHEWS DEMOLITION & EXCAVAT
NAI@: 100356 PACIFIC PETRCLEUM CORF
PPC- 4 51-
.-"-;*<
r.iart.ar- .G $rl..rq4rt
Mataria]. I
2175 _ ?1?5 DIBTY'CONCRETE VO/REBAR
Groae : Tars: Net;
9{060 tb 34440 lb 59620 lb
Ctrmul,atirrs: 0, O0Tons
llst:
29,81 tn
ltglciil4Asl:gR'S CEnTIFIi:A?A THig 1$ TO CEft?,IF? that rhe follor;ing
d*i"i:rtuo *or'rnodiry was rreiqhed' ttreasured' or ccunted by 6
*ei-qhrnaa'rer. "rhi)''e-signacuri is ori lhis cer:t1f,1care'. rho ls a
reciqnizeO aurhoricy af accuracYr a.i Prescribed tty cbapt€r
i - i".i*tn"n"ing wi ch bectiorr 12?001 of Div{sion 5 of Lhe
CeJ.ifornla Businegs and Professione Code, adrninistdred
by the Dlvisron of MeqsuremanE -ctanda.dc,of fhri
Cittrsrnta DeFaxtrnenL oi Focd and &grlsulruce'
I
PACIFIC
FETROLEUITI
CORPORATIOTTI
F.o- 8o12646 ' orcurt. cA0r4s7 - Ter: (B0s)925-1947 ' Fax; {B0f}s2g{tEB4
t
CHARGES
NUE
CHAHGES F'OT LAT€F
OF I}IIS BILL.
4il563
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a.tlt\r.
tiRS.
llltt't.
FOR OFFICF USE OHLV
lottr.50
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NAMEOF
UNDERLY'NO CARRIEB
CONSIGNOR;
DEBTOII:
POIN'TOF OFIIGTN:
DESTINA
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LOGATION
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IIFT.'ARKS
TYFE OF I
EourPMENr e,/\ 4
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r-rouFlLY
rTATE
q,*7
suRcH4nGE
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TIME
AXLgS
OF
TOTAL
ENVIRONUT${TAL FEE
Ssira Tail
1ro.-|3r3fn ad,0\?'ts<-'f10lLol-1.g)
tf,.lqJ4s*llt q-trrrln3n
l-t.r rr-1?t lrFfrr-\ iQ3a1t crPlr
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ORHEN
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SIGNAIUIiE OF
TIIAH
OFIGINAL RETAII{ED FY P.P,C.L
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Rccpt?od rN I'trturrl
Weighmaster: Sara Morris
Driver's $ignature:
TROSSH RICYCLING, INg. DBA EOXSAND
2290 fl*ttan Roacl - I'lipomo CA 93444
Phone: 805*35?-2284
Fax: 805-9e8-f196
l.rl,rw. rOXSand. net
-k*
tr-r..ri.* t-... n'{au
Net;
23.'83 tn
9/19/20L8 9:09:02 AI',l
Ticket #: 2L7422
ACCOIJNT [MS{E: 10076]. HD MATTHEWS DEMOTITION O EXCAVAT
HAUTER NAt'g: L00356 PACIFIC PETROLETJM CORP
TRUCK #: PPC-451
Po #: SLO-BRICK/REBAR EI'C
JOB ADDRESS:
JOB I}IF'O:
Matarial:
21?5 * 21?5 DIRTT CONCRETc W/gEBlJ.
Grosa: Ta.re: t{at:
82100 rb 34440 lb 4?660 1r)
Crrmulative; O.00Tons
Hr:tcttl,tAs?ER.$ CERTIFISATI Tllls ;s T4 CARTIFY lhat eh6 followirlg
dasr:rj,bed corruacdity *eas weighedr negsur€d, or c6$nced by 9
',{eigh$ta$ter, whste slgn+ture is *n this eertifj.car€. uho iu a
recogniaed auihcrity +f afcqtraclr &,$ preslrlbed b'y chapcer'i (conr'nenclng wich SecEi*ll lil0oi of ltiti.sfon i ol' r-he
Callfornla Business arid FlofEssibns Cod€, adtniaisteret!'
b!, qhe Division cf l'loasurenent Slafldards sf the
cAllfornta Departnent of food ancl Agriculture-
R,lll ?our Aflrcertc lllrdr
Aldycled ud ilelural
?ROESI{ RUCYCLING, INC' CIBA ROXSAND
228il llritton Road - Niparno CA 93444
Phone: 805-35?-2?88
Fax: 805-928-1196'
w?'rw. f O}tsand. net
9119/2frr8
Ticket S:
11;11: {6 AS
?L?4 38
ACCOUNI I{AME: 1OO?6i HD MATTIIEWS DEI4CII]T'TON & EXCAVAI
HAUT,ER NAT''E; 100356 - T'ACIFIC PETROLEUM CORP
TRUCK #: PPC*451
PO # : SLO-REBAR/PT,ASTTC
.IOB ADDRESS:
rTOB INFO;
WeiElunastar: Sara Morrls
Driver's Sigrrature:
MateriaL:
2180 - 3.180 OVE.RSIZED CONCRETE RtJBBLS
Gross: Tars: Net':
85220 lb 34440 lb 50?80 lb
CumuLativ6: 0. O0Tons
Net:
2b.39 tn
I{ulcgMn$taR,$ cgRTtl';e\?E TllIs t5 TO CERTIFY Lhaf the follo!,{!nE
descrlbed c+mrnoeiiry uae r*eighedr {lleastlf,ed. or counted lrv 1
waiqhmastef, ',those slgna[ure is ort rhi'g i:erulflcate' ubo is a
.eci,lnfzeA iruthority of accura':y' as prescribed by chapter
t {c6rynencing wlrh beceion ta?C0l of *1r'lslgc 5.o{ Lhe
Californla $u*1ness and Erofesglor,s C;r<leq adminLstored
by rhe Divlsl.an ef l'leaiurei$enL $tandardn Df Llie
cilifornia 0eg'altElerrt sf Fflad and Agrlcultur'3.
R
All Your iggr.frtl tlrrdr
Recrcr€d and N.turol
TI1OESH BECYCLING, II{C. DBA ROXSAND
?280 Hutton ltoarJ - t'lipomo CA 93444
Phone: 805-351-7289
Fax: 805-928-1196
www. ro:asand , net
9/i9/2fi18 1:18:Ct2 PM
Ticket #: 217150
ECCOUNT NA}TE: 100?6I }lD MATTHII}JS DI}4OLTTICN & EXCAVAT
HAUI.ER NAME: 100356 - PACIFIC PETROLBUIVI CORP
IRUCK #: PPC-451
PO S: BRICK ETC
JOB ADDRESS:
JOB INf'O:
Yleighroast.r: Sara Morris
Driver's Sigrnatura:
tilAterial:
21]5 - 21?5 DIRTY CONCRETE WIREBAR
r- 4.J'r€r-r!
*'--f*-
Nat:
?6. 0,3 tnGf,oss:
86500 lb
Cr.mulat,ive:
Tare:
34.1.{0 lb
0. O0Tons
Nat:
52060 lb
WEIGII{ASTIE'S C$n?rrISqtE ?fiis Is To cEnrlFY that rhe fol}owing
derscribed couunod.!,ty was '*etqhed' l:rea$urecir Fr qoulttecl hy a
w€iqhnraster, *hosE slgnattrt 1.s an this €ertif!-clte,-rrho is a
recogrrired auLhorit.y cif a.:curscy, as prescrlbed by chapter
? tr-r6nrnerrcrnq u!-th 9ec:icn 1??001 of tllvj.sir:r.3,af Lhei
Cel i fartia lJusir:ess arrd Fcof essions f,odel adninisterecl
lry ,lhe Slvlsion af udaEuiein*nt srandarris +rt' Ll"e
f;l! I f*rnia Bepart.ment 'Ji Food and Agriculture''
R
Atl to*r Allf r.irtr tl.*dl
f,egycled afi6 Nacwul
TROESH RECYCT:HG. INC. OBA ROXSAND
2280 Hutt-on Road - tlipomo CA 93444
Phone: 805-35?*228S
Fav.: 805-928-1i.96
i.rww. rcltsand , net
9lL9lzALB 4:3?;49 FM
ricket *: 217462
ACCO-TJNI !{AI,[E: 100?61 HD I'IAT?HEWS DEMOLITION E EXCAVA.''
HAULER NAI{E: 100355 FACIFIC Pn'TROLEUM COR;i
IRUCK #; FFC-451
PO #:
JOB ADDRESS:
JOB INFO:
Weighnaeter; Sara lilorris
Driver' e Sigirrature:
.jJil*.i'r
llaterial:
?1?O - 2T7O DIR?Y CONCRETE RUBBLE
L tZ--
*i*'..drid td
rwre ri..rrt r*
€roEa: Tare; Net:
?4L20 }b 34{4CI tb 39680 lb
Crrnulativo: O.O0Tons
Net:
19. 84 tn
'*EIGI|MFS?EB'.q gEtT.fTFICA'rE T'dIS :S TLI CEFI'fFY Ellal thE fsllowlng
,Jesfflbed es*nroclity'.Jis r,ceighed, ltr€isu.r€dr ol-tsunled by 3
werglrmasr.er. whosa' sl4nature :is on this .:ert'if i(:at€,. i''!ic !3 a
rrr:ignizecl authority of ;ccuractr n* Pres{:riberl by chaPter
r {e6n:nencipq ',vit}r bection 12?0'1} of Dlulsion 5 of thF
iai: forala Busjne:s anrt P.refesilcrns -f,ode. arlnrin j ste:ed
L,1r t1i1s Elvislon $f lteBFurement Sta$dards of ch€
Cil: fornia Fepa:tmenL of Foorl and I'.gr-1 cr.rlture.
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PACIFIG
PETROLEUfUI
CORP€IRATJSI{
P.o' Box 1646 ' orcu$, cA s34s? . Ter: {$05) 92s-tg4r ' Fax: (B0s} 9zs*0g04
4S5S4
*.*-$--,-Lr]- - *"1*
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FOINT OFSHIGIN;
MA .L
f.!E$f u'JA"lldlN
DRIYEIT
F.O. n
TIME
nfitE \
MEAL E
CHARGEs
DU€
CO[trdlSSlOl'J ftESUfAES pAyMEfiT FOR THES€CHAFGES t'lOT LAT€F
t.
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REfJgRT€O
TYPE OFgOTjIPMEilT
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.:/lAt5 tIr!i i._\t I l''.1il,r. L.i tiit.tN:.t \;.i-a:!{jlifi :Jlr Ir-!/jr t*r€ r:€r..itrtca.1 !{}etsri: :,6 i J: i_i.f.;:
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FOF{ AFrtI:E usf 0hri_Y
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THA$I TH€ FIFTEE'\'TII OF THa }noETH FOII-O}YI}IG OATE
fli?iil$Jfd! RF:TA,T"J'i* 8Y F.P C
}I(XJRLY
RAT€
FNESGY SUNCHNRCE
NO. OF
AXLFS
BOOY
CSPACITY
TOTAL
E 'trnROI{ltEt{TAL FEE
Saloe Tax:
\Or-ct&lo?r.t
i'i: I
{.1 i i.:r. Fi,.f ir:,triti-.i
- tli1.i:
i.,i-t ii4Ubf'J i:i,t
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ijt]ivtl'' I ;i5 i' itirii.r
jrl i .I.t':i.^,t1,.r" r;{::'i i tii}lt.
iJL ir i'i{,ri'i i.rri:i I r i'ilf,'
i'ii1.:ri: .rll. I l.- r"l
l., lr::. 4 i it :;r-riil
l',1{:hiA'itjRF fiF
oF 7Ht8 Ail-L.
9"53.{}D
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TROE.B}I RE.;YCIING, II.If . FRA F.CIXSA}iD
2.28* llul:'Lon F.oarJ - Nip*m* rjA 93444
Pfisne i 8fi5-357*228s'
fax: H05-928*1196
w';4",r, rOy.sand,net
?t2*f i.i38 lti:4€:48 AM
lFicket #: I1?469
SCcomet ;SRME; 100?6L HB MATTHEWS DE[4OIITI0]; e SXCAVATION
HAIITTEII NAIG: 100356 - PACIFIC PBTROLEUM CORP
I'RUCK #r PPc-451.
PO #:
,TOB ADDRGSS:
ilCIB rltFo:
1{e*.ghraster: $ara Morri
Sri.lrerts Sigmaterre:
#t'$- *- :---,r-ii-.*^*_1a
l{*Leria}:
?130 - 2130 MIX ASI]I.IALT/CONCRETE DIRTY
#rEss: Tare: Net:
?4?0ii lb 34440 lb {e260 lt}
CumuLative: 0.00 Tons
Ns*t:
21,13 in
vjE!.i;iil{q$?efi'$ CEFj:'lfgCAfE ?.lits 1$ TO *ERflt'Y ttrar tha f{lllnwing
{J*g(rib+.d cr:fluurdi:y t'as ce{.ghed. measured. or counted by;r
*eiql:cll*cer, *iro$e signafure is on this certif,ieace, uiro !s a
rer:r-grrieed auihori.ty of aer-uracyr as prescribed by ehapr,lr
? li:r$Efi*ncirrg r,rii:h $estioD l]?Sf,] +f ]ivision 3 of the
,'-',aii f;:rnla Bueiness and Plofessirrns Code, admiaist-e:ocl
by the DJrrisisn'nf l.Ieasur€r?t€nt Standard€ sf Lhe
(la.l. 1f*rr:ia AeF*rtment of *:ol:d and AEricul"rure.
l'
i
City of San Luis Obispo
Building & Safety Division
PermitNumbar GRAD-1710-201Q
Work Class Early Grading
Project Descriptl FUEL TANK REMOVAL & BACKFILL
ProJectAddross 1150 Laulel Ln. San LuisObispo, CA 93401
lnspection Record
Date 812U2018
lnspector
COMPLETED
FOR |INSPECT,ONS, CALL 80s-781-718A ONE DAY PRI,OR TO REQUESTED D$rE
AND PROV|,DE PEBMIT NUMBER ANDADDBESS
PRIORTA BUILDING FINAL
@
r
I
T:8ar I Suspended CeilinsFoundatlon Water-Prooting and Draimgs
Exledor Lath I FlashlngRetainhg Wall, Masonry Reinforcement
lnlerior LathLiqht, Sign. Deck, Trellls Footing
ShMer Pan LinerUfer Ground
Gas FrossuroTeslFotms, Ex€vatlon, Relnforcement, Rebar
Drywall NailingStormwater OMPS
lnsulallonRough Grading / Pad Ceflificalion
lnspectorDateSURFACE COVERINGSlnspeclorDateFOUNDATION
Tmporary Powet Pole
Post-(Snstructlon Measurest6nrmffi
Gradlng & OminageSediment Dlscharge / Track4ut
Slm DEinStablfized Entran@
Slte Wall DrainageSlop€ Stabilization
cEding / Grubblng Site Sito Wall Rsinlorment
Oust Contrcl Site Wall F@ting
Concr€te; Palnt Plaster Washouls Oeck, Trollls, Llghl. Sign Footings
Electrical ConduitsSilt Fence
Gas Piping & Prdssure TeslFiber Rolls
water ServicoSWPPP / WPCP Plans On Sits
DateSTORIUWATER Sewsr LaleEl & Backwater \ralvelnspeclor
DateSITE WORK
Windosrs
Rough MffihaniEl
Rough Flre SpdnkleF
Gas Plplng & Pressure T6t
Rough Plumbing I OWV Test
Elmt,ical
Rough FEmlng
n. fhot tn-Tthe / tar{ihffirrrFr+ I[?E DE.w,Floor Nailinq
Shear Wall Nailing
lnsp€ctorDateDEPARTMENT FINALSRoot Nailing, Tffis Layst
Post-Construdion Measures
lnspectorDateROUGH INSPECTIONS
Grading & Drainage
Smoks,l Carbon Monoxlda AlarmsUndedloor lnsulation
Gas Msler RoleaseFlmr FEming
Slairs, Hardrails & Guard RailsMschani€l Ducts
Acc€sslbllilyEleddcal Conduits
Fite SprinklerTrim & TeslGas Plping
Finish M€chanlcal & Dud TestingWater Piplng
Finlsh ElectdcalSlab Reinforcemenl & Moisture Barier
lnish PlumblngDliW Plping andTest
DatePRE.FINALlnspeclorDateUNDERFLOOR'SLAB
t FTNAL AppRovAL o^t 7J14!6,lnspector
Portial lnspecllons Noted Below
urnty of San Lti'is O,bispo crypf Esmuflswo I
P.O. Box 1489
2156 Sierra Way
San Luis Obispo, CA 93406
Fire Department (805) 781-7380
2160 Santa Barbara Avenue
San Luls Oblspo CA93401-5240
CERTIFBD T]MFIED PROGRAM AGENCY (CUPA) T
HAZARDOUS MATERIALS INSPECTION FORM
EFW data
entry by:
Date:
Time:
: lnspections may involve obtaining photographs, revlewing and copying records, and
with
TO
codes. GRANTED BY
n NO trYESREINSPECTION REQUIRED:I usrD ttw GeneratorI Business Plan EcnnnpI aer
PROGRAMS INSPEGTED:E usrI ttw GeneratorE Business Plan Icnr-meE aer
PHONE
<D I -c,t.,t {4.I I q'^a-ADDRESS: I
FACILITY NAMEI Reinspection
Other U5f
l/gA^,o-(N-
Result Gode: _70
Action Code: _32 31
Routine
Gomplaint
_80 _90
_37 _33
AGENCY
f] EHS
D AG DEPT!| crw nne
YES NO COS N/Atr[ n trtrn tr ntrr n n
nn n n!tr tr n
BPOl
BPO2
BP03
TROl
TRO2
EROl
ERO2
BUSINESS PLAN '1 t T
Business ptan is comptete, currenl & availabre'i *ptA{"*I1*sc 2ss035, Title 19 ccu272s)
Inventory of hazardous materials is complete (HSC 25504' fitle 19 CCR2729)
Site layouUfacitity maps are accurate,'(EIsC ZFSO{, Title 19 CCR2729)
lr,J r i
TRAINING PLAII
Facitity has appropriate training program (Iltle 19 CCR2132 &22C9'66265Jq
Training documentation is maintained on site for current personnel (Title 19 CCR2732 & 22 CCR
66265.16)
EMERGENCT RESPONSE PLAI\
Confingency plan is complete, updated, and maintained on site (ESC 25504' Titte 19 CCR 2731 & 22
ccR $ 6626s.s3ts4)
Facility is operated and maintained to prevenUminlmizs/ni6gate lirg explosion, or release of
hazardous materialVwaste constituents to the environment. Maintains alt required or appropriate
equipment including an alarm and communications system Clitle 19 CCR 2731 & 22 CCR66265.31-
.43)
ABOVEGROT'I\D PETROLETJM STORAGE TAI{K ACT
SPCC Plan is reviewed and certified by a registered engineer within last 5 yrs. (40 CFR 112.5(b)) 1
SPCC Plan is maintained on site or ncarest field office. (HSC 25270) {: I
trnntrxnnD
trn!nrn tr Arol
f] Aro2
COMMENTS Go to http://wu'w.slopublichealth.org/environmentalhealth/hazardols-materials.htrn, to obtain forms to comply with BP0l-BP03' TR0l and ER0l
u
*L
GPS Coordinates: Latitude: deg min decimal min
rNsPEcroR, lftl41AA^ &^*,
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informationrbat
VII. APPLICANT SIGNATI'RE
SIJPERVTSOROF SECTION, OR OFFICE (Requircd For Public Agcncies Only)
OWNER
FACILITYOWNER
INFORI\4A'TION
lssue perrnit and send legal notifications and msilings to:
VI. PERMIT
EI 4.TANKOPERATOR
EJ 5.FACILTTYOPERATOR
Call the Statc Board ofEqualizarion, Fuel Tax Division, ifthcrc are gucstions.tzr.TY(TK)HQ44-
E + locnl acENcYrDtsrRtcr
I z.neoenalAcENcY
OWNERTYPE:420.
F'EE ACCOUNT NTJMBER
NON.GOVERNMENT
AGENCY [J e.srnreecENcY
V. BOARD OFEQUALIZATION
ztpcoDE
9g,+"f
{t9.418.STATE a(A,tog Lr^u $B\.g Po
4t7-
415.
)
4t4.
t
rV. TAIYK OIVI{ER INFORIICATION
t3{st
ZIPCODE 4?&6STATE
Cr"
.2t.5'*3^r-, I**u oB\sPs
428-4
-tfi."t\)
III. TANK OPERATOR II\IF'ORT{ATION
9g{o r
ZIPCODE .il4dil.SIATE
CA
gryo
$JoL' \r.r"ts ,"ots$ Po
4t0.
MAILINGADDRESS
orlocatcd on
EYe.
ls the facility
Trust lands?
gesiryrvpE fl r.MoroRvEgrcLE - fl z.pugr"orsTRrBunoN
\,+/.omsn4. PROCESSOR[:I 3. FARM T.I
s FACILITY NAME tr DAA - Doing BEinBs As)
USTsA
t03.
FACILITYID#
Use
I z. nenunuENT FACTLITY cLosuRE
E g.TRANSFERPERMIT
I. FACILITY IIVFORMA'NON
TEMPORARY FACIUTY CLOSURE
OFINFORMATIONil r.xewrrnum
O :.Ral.rEwalpERMtr
ryPEOFACTION
(Ctcc& onc itcmonly)
I'NIFTED PROGRAM CONSOLIDATED FORIVI
UNDERGROUND STORAGE TANK
APILJ:C AflON - FACTLTTY INFORMATTON
,/ '1one formperfacility)
OPERATING PERMIT
UPCF UST-A Re% (I2l200?)
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APPLICANT o
DATETURE
in
I substance stored tnd that the information provided herein ls true' accurate'system
IX. APPLICAI{T SIGNATT]RE
STEECCOMPONENT PROTECTION 4. IMPRESSED CTJRRENT Ue.2. SACRIFICIAL
FIBERGLASSI. STEELMATERIAL
2, DOUBLE WATLI. SINGLECONSTRUCTION TYPE D 9O.NONENO DISPENSERS
4.
99. OTHER (spcciS)4.l.
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4. FIBERGLASS.I- STEELVRPRIMARY CONTAINMENT
99. OTHER (Spcci$)
PRIMARYCONT I. STEEL 4.
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WALLI
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OTHER 464c
4.I. STEEL
NONE
PRJMARY CONTAINMENT 4. RBERGLASS
95.1JNKNOWN 464s
8. FLEXIBLE
99.
STEEL
NONE
4. SAFE SUCTION ccR
L
PREVENNON
FOR EXEMPTION FROM OVENNLL PREVENTION4.MEETS
&VISUALALARMS
SECONDARY CONTAINMENT 3. FIBERGLASS T.JACKETED
OTHER 445a
STEEL
99. OTHER95. I,NKNOWN
3. FIBERGLASS
444a
STEEL
fiPEOFTANK
Jt4ObI I. OTI{ER NON.PETROLEUM
7.
8. PETROLEUM BLEND FUEL
trtl
FUEL IHSC
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'..198
lc, AVIATION FUELING
6.GAS
b. PREMIUM TJNLEADED
OTHER
EMERCENCY
E 3.DIESEL
PETROLEIJM:Ia" REGULARUNLEADED
GENERATORFUEL
E 3. CHEMICAL PRODUCT STORAGE
la MOTOR VEHICLE FLTELING
Ic. MIDGRADE TJNLEADED
OTHER PETROLEUM
FUEL
Ib, MARINA FUELING
4- HAZARDOUS WASTE{lncludB Uscd oil)
95.IJNKNOWN
ITI. TANK USE AND CONTENTS
DATE 435UST SYSTEM INSTALLED(^\JW\JASIA\)TANK
Os
INGALLONS
\I\-:KUcssu
TANKID#432 MANUFACTURER
U.\rVtl:t*rrg ONE IN A COMPARTMENTED I'NIT
I. A STAND-ALONE TANK
TANKISCONFIGUNANON:
II. TA}IKDESCRIPTION
DBA-Doing Business As)as FACILITY NAME or
IFACILIry ID # (Agency Use Only)
I. FACILITY INFORMATION
430bDATE EXJSTTNC'USr OnCOVensO: tj[ Ut<.t rtt J S4106barb usr pTnMANENTLy cLosED: Lrut^l:\G)\\
Sections I, lI, lII, IV, and lX belorv)
CHANGE OF INFORMATION
(Check one item only. For an USTpermanent closure or
El L neNewnl PERMIT
only
NEW PERMIT
ACTION
7 CLOSUREON
I
UNTFIED PROGRAM CONSOLIDATED FORM
{'NDERGROUND STORAGE TANK
OPERATING PERMIT APPLICATION _ TAI\K INFORMATION form
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PR0JECT SUMMARY.REP0RT for AT0LL H0LDING, LLC '1150 Laurel Ln, san Luis obispo. cA 93401 <-> APN 004-962-0T8
>>> TAI{K DISPOSAL REPORT >>
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WESTERN METAL CO
2910 S CherryAve
Fresno, CA 93706
Phone: 559-264-6246
RC - 3{80
Seller 19596
WILLIAMS EXCAVATION
CUSTOMER COPY
WEIGHMASTER CERTIFICATE
1074021
Tran No A 1074021
(cA)Drlve/sLicence: 88584010
244 E PRINCETON Vehicle:7V91657
FRESNO CA 93704
Commodity
STEEL U
Gross Tare Net Adj
40680 30380 10300 0.0%
UM $/TON Amount
TON $110.00
UnitPrice
$0.0550
Gross Stam 9/TareStamp 911812018 4:A9:22 PM
Total
t HEREBY STATE THAT I AM THE LAWFUL OWNER OF THE MATERIAL DESCRIBED HEREON, THAT I HAVE A RIGHT TO
SELL SAME, AND THAT FOR PAYMENT RECEIVED IN FULL, HEREBY ACKNOWLEDGq I SELL AND CONVEY TITLE OF
SAME TO WESTERN METALS CO. I DECLARE UNDER PENALTY OF PERJURY THAT THE FOPGGOING IS TRUE AND
CORRECT.
BILL OF SALE
EXECUTED AT FTesno, CA. THIS DATE:9t20t20't8 THANK YOU.
We appreciate your business!I received from Western Metal
Co the amount of
Seller's Signature
Western Metai Co. Weighmaster:
DEPUTY Lupe Rodriguez
WEIGHED AT 2910 S Cherry Ave, Fresno, CA
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PAID BY CASH
CUSTOMER COPY
THIS IS TO CERTIFY that the following described commodity was weighed, measured, or counted by a weighmaster, whose
ature is on this cerlificate, who is a recognized authority of accuracy, as prescribed by Chapter 7 (commencing with Section
1.2JA0) of Division 5 of the California Business and Professionals code, administered by the Division of Measurement Standards of the
ofFood and
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HARMLESS ACREEMENT. Seller will indemni$ and hold buyer harmless from damages, demands and liabilities, including reasonable attomey's
resulting ftom breach of any warranty hereunder and driver agrees to be responsible for damage to vehicle during unloading.
Page 1 of 1
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PROJECT SUMMARY REPORT for ATOLL H0LDING, LLC t > Project Nc. 2018-27
1150 Laurel Ln, San Luis Obispo. CA 93401 <-> APN 004-962-018
HIIZARDOUS }IASTE }IAIIIFESTS. >>
H
Window https ://mail.yaboo.com/dlsearch/nanp=KelmToluflrgglll$d{,srlmrAuur.
Subject Atoll
From: higginswmc@yahoo.com
lo:
Date: Fridav, October 5,2018, L0:30:09 AM PDT
Keith Higgins
lndependence Environmental Seruice,s, LLC
1225 S. West Ave, Fresno, Ca, 93706
PO Box 12623, Fresno, Ca, 93778
Cell: 559-243-6169
Office: 8A0-971-9A10
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Putriic reporting burrien for this coll€ction ol inirrmaticn is est.maled to average: 30 mirules for generators. 10
minutes lor l.anspg.tets. dnd 25 minules fsr o:yners cr operalsrs ot lreahant, slotage, and disposai iaciiili8s, This.rqclrdes liffre tor rcvieiYing inslructions, Ealhering da{a. c0ripleting. re!,ier/ing and transmitting lhe lorn. Any
:otrespo1Csnto regardiig th€ PRA burdex -<laiem?nl fcr lhe naniiesl nlust be sent to the Direclor ot the Coltectioni:skalegiesDivisicfiinFpA's0firceoilnlcifiarioncolrscrionallheforioyingaddr€ss: [J.s.Eovkonm€nrar ]
.Proiect;onAgencii2B2?Ti.ll00perrsti;aniai..re.,N',V_.i,.iashingi.r.DCZ046C. Oonotseod
lhe coDplcted lorn te this addr€ss_
U.S. EPA Form 8700.22
Read allinstftrctions before completing this form,
1' This rorm has been designed for use on a 12.pitch (elite) typewriter which is also mmpatible
with slandard computer printers; a firm point pen may also.be used-press down harcl'.
2. Federal regulations require generators and lransporters of hazardous waste and owners or
opentors of hazardous vraste heatment. storage, and disposal facililies lo complete this form
{EPA Form 8700-22} and. if necessary. the mntinuation sheet (EpA Form arbo-zz4 ror
bolh inter- and intrastate lransportation of hazardous vjaste.
L lnstructions for Generalors
llem i. Genentor's U.S. EPA ldenlilication f.lumber
Enter the generaiois u.s. EpA tivelve digit identificalion number, or ihe state generator
idenlification number if the generator site does not have an EpA identification riumber.
Itam 2- Page 1 of _
3lTllg total numberof pages used to conrprere this Manifesr (i.e., the tirsr page (EpA Form8700-22)ptuslhenumberofContinuationSheets(EpAformgiOUZzRl,ifanyi.-'- ': -':,:
llem 3. Emergency Response phone Number
Enter a phone number for urhich emergency response information can be obtained in the eventofanincidentduringtransportation,Theernergencyresponsephone*'n'i',it,
1 ' Be the number of the generator or the number of an agency or organizarion who is capabre
of and accepls responslbirity for provi{,'ing derailed infdnnatron abiut the shipmenq
2. Reach a phone thai is monjtgred 24 hours a day at all times the waste is in transporration
iincluding transportation relaieri siorage;: and '
Item 10. Cantainers gtumber and Type)
Enter the number 0f containefs for eacn waste and ths appropdate abbre'riation ho
(below) for the lype of container.
TABLE!_IYEES Q|_QQUIA!NE8q
BA = Btrlap, clolh, paper, or plaslic bags. DT = Dump buck.
CF = Fiber or pla$lic boxes, cartons, cases. DW = Wooden drums, ban..,
CM = Metal boxes, cartons, cases (including HG = Hopperorgondola cars
roll-offs).
CW = Wooden boxes, cartons, cases. TC = Tank cars.
CY = Cylinders. Tp = por"rable tanks.
DF = Fiberboard or plaslic drums, banels, kegs. fi = Cargo lanks (tank lrucks
DM = Metal drums, banels, kegs.
Iten 11. Tolal Quantity
Enter, in designated boxes, the tbtar quantity of waste. Round partiar units to the ne-,
whole unit, and do nof enter decimars or factions. To tre exlent practicar, report quar
using appropriate units of measure that will allow you to report quantilies with precisl
waste quantilies entered shourd be based on actual neasuremenrs or rea.onlurv i
eslimates of actual quantities shipped, conrainer capacities are not acceptabre ai r
Iten 12. Unils of Measure {WeighWolume)
Enter, in designated boxes, rhe appropriate abbreviarion from Table ll {below) for th-
measure.
TABLE II.-UNITS OF MEASURE
G = Gallons (liquids only). N - Cubic Meters.K=Kilograms. p=pound6,
L.= Liters (liquids only). T = Tons (2000 pounds);
M = Metdc Tons {1000 kilograms}. y = Cubic yards.
Nole: Tons, Metrie Tons. Cubic i",leters, and Cubic yards should only be reportsd in
conneclion rvilh very large bulk shipments. such as rail cars. lank truiks, o, burgrr.
Item 13. Waste Corles
3. Reach someone urho is either knov;ledgeable of the hazardous wasle being shipped and Enter up to six federal and state waste codes to describe each wasle stream identified
and informalion about ihe shipment. . tu"llr^
Note: Emelgency Response phone number information shouki only be enlered in ltem 3 vrhen ltem 14' Special Handling Instructions aml kiditional lnforntatian
sitalion {e'9.. consolidated shiprnents) arises lvhere more lhan one Em.rgr;.y ip;;;. lttt proper management or lracking of th. i,.r.r",irrr unl.r the generabrs or olhephone numbet applies to ihe various rvasles listed on the manifesl, tn" pnonr nurlJ."-- handler's busineis processes, such as waste profile numbers, container codes, bassocialed rlith each specific materiai should be entered after its description in ltem gb. or response guide numbers. Genentors also may use i6s space ro enter additionaIten 4' Manifest, Tracking l,lumber descriptive information about their shipped rnateriils, such as chemical names, conl
Item 5. Generatot's Mailing Address, phone Number and Sile Address
lelephone nurnber (including area c-odei should be Ste normal business number for lhe ' '
residues fhat are re-shipped under a second manifesi; and lhe specifcation of pCgenerator' or the nuntber vrhere the generalor or his aulhorized agent may be reached to descriptions and FCB ourof-service dates required under 40 cFR 761 .207. Gent..!ilT'fiJ1',ffi1lif[::'"il:il,$f;:lgi11ii#iff[i',:i$f#m,yjm,;;:f:- l;'#ffillln o,ou*,,inro,mai,ontnmisrpacetomeersrateresu,ati
only ifthis address is different than the mailing addrsss. -' r. .-"- -"o-'e'Y
llen 6. Tnnspatter 1 Company Nane. anrl U.S. EpA lD Nunber ltem 15' Genentof slOfferals Ceftiticalions
Enrerrhecompanynameandu,s.EpArDnumberorrhennu'nsporterwhowirkanspornhe 'il:,fTfH#i,1'ii'?*:tii,ri?,i,.tl:fil:lliii'::1..X#jHtliliEll;waste' Vehide or driver infoimation nlay not be entered here' d; ;-*pil; rhtu[ or r.gurufion fom the duty to make a wasre minimizatio^Item 7' Transportet 2 can'pany Name and u's' EPA lD Nunber cerlificalion undeisection 3002{b) of RCRA are also certifying lhat they have comrlf applicable, enter lhe company name and U.S. EPA lD number of lhe second kanspoder whp with lhe waste minimizalion requiremenls. The Generatois Cerlification also contwill transport the wasle' Vehicle or driver information may not be entercd here. Iequired atlestation lhat ihe.shipment has been propertylrepared and is in proper
Itens.DesignatedFacitilyNane.srfeAddress andIJ.S.EpAIDNumher cerlilicalionstatementisasfollows:'l herebydeclaretnatrnecontenrsoithir-"''-
IdentifrcationNumber'anclPackingGtoup)
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wnenapirtvotteiinaninegenerarorpreparestheshipmentforrransporrafion,fits
Iten 9a' rf rhe wastes identified in rtem gb consist of both hazardous and nonhazardous rnay aiso sign rhe shippecs cerrifcation'sratemeni as rrri offeror.of the shipment.
conesponding hazardous materiai identified in ltem gb' btock or may nanJ unlnJiris statement in the signarure block prior to signing tre 1
Number.(uN/NA)and.PackingGroupforeachwasteasidentiliedin4gCFRtiz. rnJuoe- ottrrnu*roilr;;;i:--'
tschnical name{s) and reportable quantity references, if applicable. ruotr' N oitnu rnou, into-.tion except the handrvritten signature required in ltenr 1-Note: lfadditional space is needed for waste dedcriplions, enler lhese additional descriptions be prearinled.
in ltem 27 on the conrinuarion sheet EpA Form gz0o-zzA). Aiso, if moie than one r
iEmergen_cv Response phone number appries ro rhe variouJ"ii;; ;;rqib;Jin eiitrer rtem gu
$ilif;fl;:ll;i:#'#ii:y,:Jg. Response phone nu*ueo in'*eoiurerviorro*i.s ihu-- :
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TBANSPORTER'S GOPY'r.-.
u,J. EFA FOrm 6rUU.ll
Read allinstfllctions before coupleting this hrm.
1. This form has been designed for use on a 12-pitch {elite) typewriter which is also compatible
with $andard computer printerc; a firm point pen may also be used-press down hard.
2, Federal egulalions require generators and transporters of hazardous v/aste and owners or
operators of hazardous waste keatment. storage, and disposal facilities t0 complete this form
{EPA Fom 87110-22} and. if necessary. the continuation sheet (EpA Form 9700-22A} for
both inler- and intrastale transportation of hazardous waste. .
Public reporling burder lor ihit collecl;0n of iei!rnat!0n is est;mated to 6verage: 30 minules fci genentors. 10
ninulesf0rtnnspqrters,and?5minutesfcro*nerscroperalorsoflr€almenl,storage,andCisposalfaciljties, This
rloludesliDefo.revie*ingioslructisns.gatheringdala.compleling.revievingandkansmi[;nglhelorm. Any
c0trespixdence re-oardin0 !he PRr\ burden slaie".l:ril tcr the manif€st nusl be seni to tiie Direclcr oF the Collection
stralsgies Difisian in EPA's Qilice oilnfarmation collection ailhe folloi,jing address: U.s. Envlronmenlal
Ptolecl;cn Agency i28??Ti. ii00 Ferrsyirani? .r.je., li',i'.. i'y'ashinglon, OC 20460. Do rot send
the completed lorm to lhls aodress.
ten 1 u, uqmaneIs {Number and I we)
Enter the number of ccnlainers for each wasle and the appropriale abbreviation from Table I
{below) for lhe type of container.
TABLE I.-TYPES OF CONTAINERS
BA = Burlap, cloth, paper, or plaslic bags.
CF = Fiber or plastic boxes, cartons, c€ses. '
CM = Metal boxes, cartons, cases {including
roll-offs).
CW = Wooden boxes. carlons, cases.
CY = Cyiinders.
DF = Fibeboard or plasticdrums, banels, kegs.
DM = Melal drums, banels, kegs.
; Item 11 . Total Quantity
Enter, in designated boxes, the total quanlity ofwaste. Round parlial units to the nearest
whole unit, and do nol enter decimals or fractions. To the extent praclical, rsport quanlities
using appropriate units of measure that will allorv you lo repori quantilies wilh precision.
waste quantities enlered should be based on actual measuremenls or reasonably accurate
eslimates of actual quantities shipped. conlainer mpacities are not acceplable as estimates
llem 12. Unils of Measure lWeightNolume)
l
Enter, in designated boxes, ihe appropriate abbreviation fiom Table ll (below) ior the unit of
measure.
TABLE il.--UNtTS oLMEASURE
L lnstructions for Generators
Ilem 1. Generator's U.S. EPA ldentifrcation llunber
Enter the generators U.S. EPA irvelve digit itlentffication number, or lhe State generator
identification number if the generator site does not have an EpA ldenlilication number.
Item 2. Page 1 of __
Enter lhe total number of pages used to complete lhis lrlanifest (r.e., the lirst page (EpA Form
8700-22) plus the number of Continuation Sheets (EPA Form 8700-22A), ifanyj.
Iten 3. Emergency Response Phone Number
Enter a phone number iorvrhich emergency response informalion can be oblained in the event
of an incident during iransportation. The emergency response phone number must;
1. Be the number of the generator or the number of an agency or organization who is capable
of and accepls resp0nsibility lor providlng delalled intoffnation about the shipment;
2' Reach a phone thai is monitored 24 hours a day at all limes the waste is in transporlation
{including transportation related storage); and
3. Reach someone vrho is either knovledgeable of the hazardous vraste being shipped and
has comprehensive emergency response and spiilcleanuplincident miligalion information
for the material being shipped or has immediate access to a person lvho has that knowledge
and iniormalion about the shipment.
Note: Emergency Response phone nunter informaiion should only be entered in llem 3 urhen
there is one phone nunber that applies to all the wasie maierials described in ltem gb. lf a
situalion (e.9.. consolidaled shipments) arises'rvhere more than one Emergency Response
phone nilmber applies to lhe various rvastes listed on the rnaniiest, the phone numbsrs
associated rvith each specific material should be enlered alter its description in ltem gb.
Iten 4. ManifestTracking t'lumber
This unique tracking number must be pr€"printed 0n ths manifest by lhe forms printer.
Iten 5. Generator's A4ari{trg Address , Phonb Number and Slte Address
Enler lhe name of the generator, the mailing address to which the completed manifest signed
by the designated faciliiy should be mailed, and lhe genentor's telephone number. ttotel the
telephone number (including area code) should be lhe normal business number for lhe
generator, or the number v;here the generator or his authorized agent rnay be reached lo
provide insiructions in lhe event the designated and/or altemaie {if any) facility rejects some or
allaf lhe shipment. Also enterlhe physical site address from which the shipmenioriginates
only if this address is dilferent than the mailing address.
Iten 6. Tnnspofter 1 Company Nane. and U.S. EpA lD Nunber
Enterthecompanyname and u.s. EPA lD numberof lhefirsttransporterwhowilltransportthe
waste. Vehicle or driver informalion may not be entered here.
Item 7. Tnnspater 2 Conpany Name and U.S. EpA lD Number
lfapplicable, enierlhe company name and u.s. EpA lD number of the second transporter who
will lmnsport the u/aste. Vehicle or driver information may not be entered here.
If more than hflo transporters are needed, use a conlinuation sheet(s) (EpA Form g700-22A).
Iten 8. Mslgnated Facilig Name. Srte Address, and U.S. EpA ID Nunher
Entertlre company name and site address 0t lhe facility designaled to receive lhe urasle lisled
onlhismanifest, AlsoenterlhefacilitysphonenumberandtheU.S.EpAtwelvedigit
identification number of the facility.
Item 9. u.s. Dor Description (lnctuding proper shipping Name, Hazard class or Division.
ldentifrcation Number, and Packing Group)
ttem 9a, lf the wasres idenlified in ltem gb consisl of both hazardous and nonhazardous
materials, then identifu lhe hazardous materials by entdring an "K in lhis ltem next to the
conesponding hazardous material identified in ltem gb.
llem 90. Enter the u.s. DOT Proper shipping Name, Hazard class or Division, ldentification
Number (uNlNA) and Packing Group for each waste as identified in 49 cFR 1 72. lndude
technicai name{s) and reportable quantity references, if applicable.
ilole: lf additional space is needed for rvaste de6criptions, enler these additional descriptions
in ltem 27 on lhe Continuation Sheet {EpA Form 0700-224)_ Also, if more than one
Emergency Response phone number applies lo lhe vadouC wastes described in eilher ltem gb
orltem 27, enter applicable Emergency Response phone numbers immediately following the .
shipping Cescriptions for those lterns.
G = Gallons (liquids only).
K = Kilograms.
L = Liten (liquids only).
M = Melric Tons (1000 kilograms).
DT = Dump lruck.
DW = Wooden drums, banels, kegs,
HG = Hopper or gondola cars.
TC = Tank cars.
TF = Poriable lanks.
TT = Cargo tanks {tank bucks),
N = Cubic Meters;
P = Pounds.
T = Tons (2000 Pounds).
Y = Cubic Yards.
Nole: Tons. fuletric Tons- Cubic i,'leters, and Cubic yards should only be reported in
connection rvith very large bulk shipments. such as rail cars, tank trucks, or barges.
llem 13, Wasfe Codes
Enler up to six federai and state waste codes to describe each waste stream identified in lten
9b. $tate vraste codes that ae not redundant lvith federal codes must be enlered here, in I
addition to the federal waste codes which are most represenlalive ofthe properties of the
ivaste.
ttem 14. Speciel Handlrhg lnsfruclfons and Additiona!lnfornation
1. GeneraloB mey enter any special handling cr shipmenFspecific informalion necessary for
lhe proper management or tracking of the materials under the generator,s or other
handler's business processes. such as waste protile numbers, container codes, bar codes
or response guide numbers. Generators also may use this space to enter additional
descriptive information about their shipped materials, such as chemical names, constituen
p€rcentages, physical state. or specific gravity oi wastes identilied with volume units in
Item 12.
'2. This space may be used io record limited types of federally required information for which' , there is no specific space provided on the manifest, induding any alternate facility
designalions; fte manifest tracking number of the original manifest for rejected wastes and
residues thal are re-shipped under a second manifesL and lhe specification of pCB waste
descriptions and PCB out*Fservice dates requiied under 40 cFR 761 .207. Generators, i
i#iH.ai:ol
be requhed to enter informalion in this spac€ lo meet stale regulatory :
ttem 15. Genentoi{Offerar s Certifiatons
1. The genaator must read, $gn. ancj date the waste minimization certificalion statement. lr
signing the waste minimization certification stalement, those generators who have not
been exempted 5y stafute or regulation fiom the duty to make a waste minimhation
certification under seclion 3002ib) of RCRA are also certifying that they have complied
with thi waste minimization requiiements. The Genenatois Certfication also contains ttrer
requiredatteslalionthattheshipmenthasbeenpoperlypreparedandisinproper
condilion for lransportation {the shippeis cerlificalion). The conlent of the shippefs I
certificalion starement is as foilows: -r hereby declare that the contents of thi$
clnsignmenl are fulry and accuralely described above by tre proper shipping name, and
are dassified, packaged, marked and labeled/placarded, and are in all respects in prooeri
condition for transport according to applicable intemalional and nationat govemmentai l-
regulalions. lf export shipment and I am lhe primary Exporter, I certity trit me contents of
this consignment conform to the terms of the attached EpA Acknowledgment of conssnt."
when a parly olher lhan the generator prepares the shipment for transiortation, this oartv
may also sign the shipper's cenificalion statement as lhe offeror of lhe shipmenl 'i
2. Generator or offeror personnel may preprint tre words, 'on behalt ofl in lhe signature
blod< or may hand rrwite lhis slatemenl in lhe signature bloct piior to signing tri
generalor/offeror cenification, to indicate lhat the individual signs as the emptoyee or agen
of the named principat. '
I
Noto: Alloftheaboveinfonirationexceptthehandwdfiensignaturerequiredinltem1bmay
be pregrinted.
i
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Ffirn OMBNo.205S00S
TRANSPORTER'S COPY
Read allinstructions before conpleting this brm.
1. This iom has been designed for use on a 'i2-pitch (elite) typewriter which is also compatible
wilh slandard cornputer printers: a frm point pen may also be used-press down hard.
2. Fedenl regulations require generators and transpoders of hazardous vJaste and owners or
operators of hazardous waste lreatment, storage, and disposal lacilities to complete this form
{EPA Fom 8700-221 and. if necessa4,, the continuation sheet (EPA Form 8700-22A) for
bolh inter- and intrastale kansporlation of hazardous waste.
Public reporting burden fo. ihij .ollec{ion of iri3rmalion ls estinaled lo average: 30 Inioutes for generators. l0
minutes l0r Iransporl€rs, and 25 minuies for c$rets cr 0peratcrs o! lreatmsnt, slorage, and disposal iaciiilies, Th:s
ircirdes lime for reviening inslructions. gathering date, completing, revieyring and transmitling the fom- Any
correspridence regetding lhe FRA burdto st;ien;nt rcr lhe macifest musl be sent to the Direclor ol the Collectjon
.slralegiesDiviii0nlnEPA's0tficeof lnformalioncollectionatthefol:oHingaddress: u.s.Enrironmentnl
,PtoleclicnAgenc:,.i2822T1.'i200Per:rsyiraniaA...e.,N',f..1'iashingicn.DC20160.0onots€nd
the conpleled lorn to lhis address.
tteffi 'lu. t;annners wumber and I we)
Enter the number of c0ntainers fcr each waste and the appropdate abbrevialion from Table
(below) for the type of container.
W
BA = Burlap, cloth, paper, or plastic bags. DT = Dump truck,
CF = Fiberor plastic boxes, cailons, cases. DW = Wooden drums, banels,
CM = Melal boxes. cartons, cases (induding HG = Hopperorgondola cars.
roll-ofis).
CW = Woorlen boxes. carlons, cases. TC = Tank cars.
CY = Cyiinders. TP = Portable tanks.
DF = Fiberboard or plastic drums, barels, kegs. TT = Cargo tanks (tank trucks).
DM = Metal drums, banels, kegs.
kegst
I
' lten 11. Total Quantity
Enler,indesignatedboxes,lhetotalquantilyofwaste. Roundpartialunitstolhenearest j
whole unil, and do rot entef decimals or fractions. To the extent praclical, report quantilies
using appropriate unils ofmeasure thatvrill allow youto reportquantilieswith precision. I
Waste quantilies entered should be based on actual measurements or reasonably accurate
eslimates of aclual quantilies shipped. containei capacities are not acceptable as eslimaies
Iten 12.llnils of Measure lWeighWolume)
Enter, in designated boxes. the appropriaie abbreviation ftom Table ll (below) for the unit of l
measure.
TABLE II..-UNITS OF MEASURE I
l. lnstructions tor Generators
Iten 1. Generator's U.S. FPA ldenli{ication I'lunber
Enterlhe generatois U.S. EPA twelve digit identificalion numbel or the Stats generator
identification number if the generator site does not have an EPA identification number.
Item 2. Page I of _
Enter the lotal number of pages used t0 complele lhis Manifesl (i.e., the flrst page (EpA Form
8700-22) plus ihe number of Continuation Sheets (EPA Form 8700-224), if any)^
Item 3. Emergency Response Phoire Number
Entet a phone number for vrhich emergency response informalion can be oblained in the event
of an incident during transportalion- The emergency response phone number musl:
1. Be lhe number of the generator or the number of an agency or organization who is capable
of and aocepts iesponsibility for providlng detailed infomation about the shipment;
2. Reach a phone that is monitored 24 hours a day at all iimes the waste is in lransportation
(induding transportation related storage): and
3. Reach someone vrho is either knovrledgeable of the hazardous lvasle being shipped and
has comprehensive emergency response and spill cieanupfincidenl mitigation infornralion
for the material being shipped 0r has immediate access to a person who has that knowledge
and information about the shipment.
Note: Emergency Response phone num.ber infomation should only be entered in ltem 3 when
lhere is one phone nun:ber that applies to all the wasle materials described in ltem gb. lf a
sibralion (e.9.. consolidated shipments) arises where more lhan one Emergency Response
phone number applies to the various vrastes listed on the manifest, the phone numbers
associaied vdth each specitic materiai should be entered after its descdption in ltem 9b.
Iten 4. Mani{estTtaehing Number
This unique tracking number musi be pre.pdnted on ihe manifest by lhe forms printer.
Item 5. Generator's Mailing Address, Phone Number and Srfe Addless
Enter the name of the generator, the mailing address h wh:ch the completed manifest signed
by the designated faciliiy should be mailed, and the generator's telephone number. Note, the
telephone number (inc:luding area code) should be the normal business number for the
generator. or lhe number vihere the generator or his aulhorized agent may be reached lo
provide instuclions in the event the designated andlor altemale (if any) facility rejects some or
all of tre shipment. Also enter the physical site address from which lhe shipmenf originates
only if this address is dilferent than the mailing address.
Item 6, Tnnsporter 1 Conpany Name, and U.S. EpA tD Nunber
Enter the company name and u.s. EPA lD number of the first kansporter who will transpon the
wasle. Vehicle or driver information may not be enlered here.
Item 7. Transporter 2 Company Name and U.S. EpA lD Number
lf applicable, enter the company name and u.s. EPA ID nunrber of the semnd transporter \,rho
will transport the'naste. Vehicle or driver informalion may not be entered here.
lf more than two transporters are needed, use a continuation sheet(s) (EpA Form g700-22A).
ftem 8. Designated Facility Nane. Srle Address, and L).5. EpA lD Nunb)r
Enterthe mmpany name anci site address of lhe facility designated lo receive he waste listed
on lhis manifest- Also enter rhe facility's phone number and the u.s, EpA twelve digit
idenlitcation number of the facilig,
Item 9. U.S. DOT Desaiptian (lncluding Proper Shipping Nane, Hazard Ctass or Division,
ldentification Nuntber. and Packing Group)
llen 9a. lf the rvastes identilied in ltem gb consist of both hazardous and nonhazardous
materials, then identifu lhe hazardous malerials by entedng an 'X, in lhis liem next to the
conesponding hazardous material idenlilied in ltem gb.
flem 9b, Enter the u.s. DOT Proper shipping Name, Hazard class or Division, ldenliflcation
Number (UN/NA) and Packing Group lor each wasie as identified in 49 cFR 172. lnclude
technical name{s) and reportable quantity references, if applicable.
Note: lfadditional space is needed forrvaste deicriptions, enterlhese additional descriptions
in ltem 27 on lhe Continuation Sheet (EPA Form 9700-22A). Also, if more than one :
Emergency Response phone number applies to ihe various wasles described in either ltem 9b
or ltem 27, enter applicable Emergency Response phone numbers immedialely following the
shipping descriptions for lhose ltems-
Note: Tons, l\,letric Tons, Cubic Meters, and Cubic Yards should only be reportsd in
connection lvith 'rery large bulk shipments, such as rail cars, tank trucks, or barges.
llern 13. Wasfe Codes
Enter up to six federal and state waste mdes io describe each wasle stream identilied in lten
9b. state wasle codes that are not redundant with federal codes must be entered here, in ,
addition to the federal rvaste codes which are most represenlative of lhe properties of lhe
r^laste,
IIen 14. Special Handting lnstructions and Additiona! tnfornation i
1. Genentors may enter any special handling cr shipmenlspecific informalion necessary for
the proper management or backing of the matorials under lhe generator,s or other
handler's business processss, such as waste profile numbers, container codes, bar codes.
or response guide numbers. Generaton also may use this space to enter additional
descriptive information about lheir shipped materials, such as chemical names, constiluen
percentages, physical state, or specific gravity of wastes identilied with yolume unils in
Item 12.
2. This space may be used lo record limited types of federally required information for which
there is no specific space provided on the manifesi, induding any altemate facilily
designations; the manifest tracking number of the original manifest for rejected was.tes and
residues that are re-shipped under a second manifest; and the specilication of pCB waste
descriptions and PCB out-o'r-service dates requhed under 40 cFR 761.207. Generators, j
however, cannot be requked to enter information in this spacs to meet state regulatory
irequirements. r
ttem 1 5. Genentofsr?fferofs Ceniftcations
1. The generaior must read, sign, and date the waste minimizallon certification staiement- lfl
signing the waste minimization certificalion sbtement, those generators who have not
been exempted by statute or regulalion from the duty to make a waste minimhation i
cerlificalion under section 3002(b) of RCM are atso certitying lhat they have conrplied
with the waste minimization requhemenls. The GeneratoCs Certification also conlains lhe,
required attestalion that the shipment has been properly prepared and is in proper
condition for transportation {the shippels cerlilication). The content of the shipper's
certilication statement is as follows: 'l hereby dedare that the contents of this
consignmenl are fully and accuntely described above by the proper shipping name, and
are classified, packaged, marked and labeled/placarded, and are in all respects in proper i
condition for lransport according to applicable intemational and national govemmentai l-
regulalions. lf export shipment and I am the primary Exporter, I cerilfl that the content$ of
this consignment coniorm t0 the terms of the attached EpA Acknowledgment of consent."
when a party other than the generator prepares the shipment for lransportation, ttris partyi
may also sign the shipper's cerlification statement as the olferor oflhe shipment. '
i
2. Generatororofferorpersonnel maypreprintthewords,'onbehalfof inthesignature I
block or may hand wite lhis slatement in the signature block prior to signing the
generator/offeror cerlilication, to indicate that the individual signs as the employee or ageriofthenamedprincipat. -
I
llote: All'of the above information except the handwrifien signature required in ltem 1s may
I
be pre-prinled.
G = Gallons (liquids only).
K = Kilograms.
L = Liters {liquids only).
M = Meldc Tons {1000 kilograms}.
N = Cubic Meters.
P = Poundd.
T = Tons (2000 Pounds).
Y = Cubic Yards.
I
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PROJECT SUIIIARY flEP0RT for AT0LL H0LDII{G,._!IC r > Prcijebt N9.. 201&127
1150 Laurel Ln,.5an'Luis 0bispo. CA 93401 <-> APII 004-962-0fB
REPORTING COMPLETE
El'lD 0F REP'RT
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PR0JECT SUI,'IMARY REPORT for AT0LL H0LDING, LLC t > Project No. 2U.18-27
1150 Laurel Ln, San Luis obispo. CA 93401 <-> APN 004-962-018
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PR0JECT SUI,IMARY REP0RT for AT0LL HOLDING, LLC t > Project No. Z0IB-27
1150 Laurel Ln, San Luis 0bispo. CA 93401 <-> APN 004-962-018
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