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i <br /> Plea9e 'nt or .(Form deslgr>ed for use on eft �h)"writer.) s' Form Approved:lNv1B No.20500039 <br /> utalFOR1e HAZARoous , Generak+r ID Number � 7012485M0MwOwt JJ K <br /> UNIFORM <br /> WASTE KAZMO C A 6 5 7 2 8 9 0 0 4 9 f' soar-oral-�e�e <br /> $ `f tS X.7C 1111"(GJliib s rMANIFEST <br /> 0m-,. C-4wator's Sao Address fit different than maifug address) <br /> a=S.AIRPORT MY <br /> STOCKTON CA OM <br /> Generaws 7 0 9 2 8 3 - d 4 Z l <br /> 6.TrgnWorhu 1 Company Name 1 U.S.EPA ID Number <br /> BLACK GOLD tM1EDUSTRIES • �T' `1 C A D B 8 3 6 0 8 6 7 8 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.DeWated Faaity Name anid SAO Address U.S.EPA ID Number <br /> Us ECOLOGY <br /> BEATYW8DOQ3 NVT33D01 0000 <br /> Facws Phare: OM - <br /> ga. 9b.U.S.DOT Desa"on(srdudarg Proper Slipping Nana,Hazard Class,ID fi+nlMf.; 10.containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Padtine Grafi(d artyU No Type Quantity VAM. <br /> 1iQmaCRAHWArdomittiWft,SW Ma oor+tarAil�ll�vi�dts�i � M2 <br /> 002 cm 54.110 P <br /> z 2. <br /> LU <br /> I <br /> 3. <br /> 14.Special Handsg Irutiucti"M and AddiUorral hformetioo 4 <br /> 1.(I1f:080i) ,• 2 x 20 CYO Fall—off ding <br /> SMOG-12—D-000S DO 0991 <br /> 15, GEmERATOR-"FEROR'S Cff T1FICATION: I hereby declare that the wn*,t3 of Bus araipr—t are tiny and accurately desabed above by the proper sttip*Q mane,and are dasvW,padw*, <br /> marked and WAedtbcarded,and are In a1 respects in proper=dliar for tranepnrt amor*lg b appi triemabonal ad national gavemnrenbl regrlatiom.If e%pW sing mru and l am the Prbnary <br /> Fporbr,I cw*that 8e canards of ft mrls►gnmant omftgrn to the tenn9 of the enacted EPAAdatiwladgnerd of Consent <br /> I oertlfy tlrat the ncwr+eaeorr C•atenem Identt8ed in IdCFR 28227(a)(01 an a fuse w�A 9ereraW Dr(b)(d I an a small quant ty 9enerato�is sue. <br /> C-Am �'slofferors Pr+llfedfTyped Name Marth Year <br /> 16.tntaiMonal R ❑Import to U.S. ❑EVort from U.S. Port of arty/* <br /> z Trano-*s.*—(tor mats *): <br /> Data leaving U.S.: <br /> w 17.Traeportar Adanwledgrtent of Receipt of Materials <br /> p yped N" Sigr a Month Day Year <br /> Trargortar <br /> < . C-i--S�r <br /> 22 yped N Signature Mardh Day Yea <br /> 115 <br /> 18.Disaepanq <br /> 18a.DisugW cy Wd cation Spam ❑ Onanyty ❑Type ❑Residue ❑Partial Rejection ❑RA Rejection <br /> r.... Manifest Reference Number. <br /> r~ 19b.Alternate Faaily(or Genenar) U.S.EPA ID Number <br /> V <br /> Faatilys Phone: Mccth Day Yox <br /> W 18c.Sgt,-nn of Alternate Fsckty(a Generator) <br /> 19.Huw trs Waste Report Manegerrent Method Codes p.e.,codas for Feraudova waste treatmad,disposal,and reeyding rystems) <br /> G 1 2• 3• 4. <br /> 20.Destgn;*FaaMy O%~or OPMW C&ttilmWn of receipt d haze ftA matertaLv covered yr Bre nenifaet as odea in item 1 Ba <br /> re MOM, Day year <br /> EPA Fo 22'ev. ) PieviowO&Oons W 06S&i- TRANSPORTER'S COPY <br />