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r � J <br /> Please int or s.(Form designed for use on 0"0(1&phch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manlking Number <br /> WASTEGANIFEST C�,LODOpgy.>,p3 1 91E-:71-E7.17 06,90 <br /> 550388 JJ K <br /> 5.Gererebffs Nama aM Mailing Address Generaws SINAddream in different than mailing address) <br /> ta1EPCO LABEL SYSTEMS <br /> 1318 S.STOCKTON ST. 29 N.ALRORP,ST. <br /> LODI.CA 9524ri STOCKTON.CA 95:72 <br /> Genereiofs PlwnrLC3-_4H+]eDt <br /> 6.Tfanspoder 1 Company Name U.S.FPA ID Number <br /> FO.MOS SER'•ACES Cn�?.dn3a5n <br /> 7.Trenapoder2 Company Name <br /> U.S.EPA ID Number <br /> 0.Oe0wanad FadNy Name and SileAddress. U.S.FPA ID Number <br /> °:EOU4 Es'.TcLri;4ICAL SOUJTInI9S, LLC <br /> 1127 HENSLEY STREET fhTL'RJL'ikO7, <br /> RICHNIOND,CA 94801 <br /> °iaJ• 43.2s32 <br /> FecAys Phone` <br /> ge, 9b.U.S.DOTOesalpllunr(mduding ProperSNppirg Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit 13 Waste Cotles <br /> HM and Packing Group(f an <br /> No. Type O sty WtNd. <br /> 1• PlOtd•RCRA HP?ARDOUS%N'A.STE Ur11J10 (ilvl <br /> GT <br /> 2• .410,x 12-CA4 y <br /> Dar <br /> 4, <br /> ) <br /> 14.Spedal Harding Instructions andA AUonel Information ) <br /> !{AIdDLERSTCIBETR;-INED. Vag ` 941) ERG#171 V41P"3' -'WtL <br /> "ER" COfdTRACTOF,: FWAOS &Y-ARONNIENTr.!SER%ACES. ZZ 17-K S <br /> r 94a <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consgnmentare fully and eccuretelydesrnTed above by Us propershlppfng name,and are classified,packaged, <br /> marked and labeMtlfplararded,and are in all respects In pmperowditionfortrareporl aaadng to applicable international and national gwwraonlal regulations.If export shipment and I am the Primary <br /> Exporter.I certify that the mntenls of this oanrgnmed conform to the terms of Ude attached FRAAcknoWedgmem of Consent <br /> I cergy that the avede minimization statement Identified In 40 CFR 262.27(a)(if I am a large quantity generato)or(b)(ifI am a small quantity generator)Is we. <br /> Genemmes)(terofs PrinterOyped Name Signature Monts Day Year <br /> moi- ��• , � <br /> —t 6.InlemaUasl aiNpmerrs P <br /> t �! G J <br /> 'rL Import to U.S. ❑Fxpoithmn U. . Pat ofentrylexil: <br /> z Trampoder signature(for exports only): Date leaving U.S.: <br /> w 17.TsnspodazgcWimdedgment of Recelpl of Materials <br /> Transporter PdnledlTyped NamaIFL,( Signa <br /> Month Day Year <br /> R Trenspalar2 PrtntedRypetl Name Signature Month Day Year <br /> 10.Discrepancy <br /> 18a.Discrepancy Indcefion Space ❑ OuantBy ❑Type ❑Residue ❑Partial Rejection ❑FWI Rejection <br /> Manifest Reference Number. <br /> 1it.A8emate Facility(or Generator) U.S.EPA ID Number <br /> _.1 <br /> U <br /> Facllityys Phone: <br /> Q10a SgnaNre ofAltamale Fadrdy(or Generator) Month Day Year <br /> Z <br /> 19.HazardousWaste Report Management Matlmd Codes(i.e.,codes forhavardouswaste treatment,disposal.and recycling systems) <br /> 1. 2. 3. 4. <br /> 20.Designated Facility Owneror Operator.Ce%fication of receiptof hazardous materials cowered by the mantlestexcept as noted In Item l8a -- <br /> PMtc&Typed Name Signature Month Day Year <br /> FFA Farm 8700-22(Rev.3.05) Previous editions are obsolete. - DESIGNATED FACILITY TO DESTINATION,STATE(IF REQUIRED) <br />