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; • 0 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1 e r rye({b ryn q�,q�pq-gg py 2.Pae 1 of 3.Emergency Response Phone 4.Manifest TrackingNumber <br /> WASTE MANIFEST ^��+�02`+'*�3 N g 551+877-5282 � � GBF <br /> 5.Gepe,(<7tg(SNaQ�g,and MailDu9ddress Generators Site Address(if different than mailing address) <br /> 3912[CNLAAVRLK DRIVE <br /> STOCKTON. CA 95205-M1 <br /> Generators Phone: �f.192-I92 r <br /> 6. Gompany Name <br /> wacydIK saiiiic iiit 7iee�a((�r1IC7vivm .rs v e <br /> 7.Transporter 2Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> CH1 Ri oWinp Service Inc WIM00029751 <br /> 101 Hagen Or <br /> Woodvi8e. Y41 54026 SM-241-2Oil <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total - 12.Ung <br /> HM <br /> and Parking Group it any)) N. Type Quantity M.1vol. 13.Waste Codes <br /> 1. <br /> 0 Non-RCRA Hazardous Waste Solid J DM 49�J P 223 <br /> Z z 1 his Upy I' <br /> W <br /> CERTIFiGr! ( - <br /> r'vING <br /> 3. F3y.. Date q 1(110� -- <br /> 4. <br /> i <br /> '4X-, l Handlin Instructions and Additional Information <br /> ear Meotive Clothing and Eyewear. 9.1 - OILY ABSORBENT E.R.G.-9 t #171 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of Nis consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.dexpod shipment and I am the Primary <br /> Export I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgm t of Consent. <br /> Ice that the waste minimization statement identified in 40 CFR 262.27(x)(d I am a large quantity gemrereto or(b)(if I a small quantity generator)is <br /> en es/Offema's Prin yped Ngml�- S ria a / Monti Day Year <br /> i r o -� l ' <br /> .Intemotional Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port otentry/axil: <br /> ransporter signature(for exports only): Date leaving U.S.: <br /> 7.Transporter Acknowledgment of Receipt of Materials <br /> ltkn er 1 PnntedlTyped Name / j Signature % Month Day Year <br /> T er Ryped Name ignature Month kilay Year <br /> d' <br /> r <br /> ♦ 18.Disorepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑FuII Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> mai Fadlitys Phone: <br /> w 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> d-i 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.DeHIs'ignaated Facility Omer or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> sill Prigtedrfyped Name Month Day Year <br /> \X7 e. n � F Si k <br /> EPA Form 870022(Rev.3 5) Previous editionla are obsolete. i <br /> DESIGNATED FACILITY TO GENERATOR <br />