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Please l/� I <br /> e se print cl type.(Form designed far use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST 1 1-1300-468-1760 10-009l14,106 V K V <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> TRUCK CENTER <br /> A Tit- ROBER FARRELL PO BOX 6463/825 NAV <br /> '^r'y'a K'I fm CA 95206 0460 <br /> Generator's Phone., pR;�9a­"144-5621 <br /> S.f P SPF ®`{C4 .t 'Am ? T r U.S.EPA ID Number 1,Xrr()0�0501y 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address SAFE 1TY-KLEEN SY'FTCM" �? U.S.EPA ID Number <br /> 6000 8BTH STREETWRAMENTO q <br /> Y tsar.— rs b 3 CA�tit�000 451 <br /> Facility's Phone: <br /> 9a 9b.U.S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12,Unit <br /> 13,Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity WL.NoI. <br /> 1 l tt:lN...R CRA HAZARDOUS WASM LIQUID r 0 134 <br /> Z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.Special HandringInstructions and Additional Information S;4 TRCK#109041692 0035444444 000370 81 0750 424 <br /> nl" , AU MC3RIZED TO RETAIN #ICA:id;s'0 UBSCOUENT i:ARR11'€+S AS i ECESGA"C( <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the cortents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are it all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GoneratorslOfferors Printed/Typed Name Signature Month Day fear <br /> �", rf''� Jr � ;' .•Y �"Sr�. /�'',�,�yl .,r.r .,�,,,,.,qrC.� r �^'�..,�;"•`�.M ""�`'a �-�:..-..,�. fi{�,+ r. ,f <br /> 16.Infemational'Shipmdnts r <br /> r- L Import to U.S. ❑Export from U.S. Port of erntry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transport 1, 'ntedfTyped Name Signature u - r .� „ y�,,. Month Day Year <br /> OCn <br /> Q Transp iter 2 Prin edlTyped Name Signa "'" Month Day Year <br /> lY <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Partial Rejection j <br /> ❑Residue ®Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> u. Facility's Phone: <br /> w 18c,Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. ji,l 41 2. 3. 4. <br /> Ll20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedrryped Name Signature Month Day Year <br /> EPA F m 8700 22(Rev.3-05) Previous edit ns are obsolete. <br /> ��.. , �;,?r,��; ;Q ,�) GENERATOR'S INITIAL DOPY <br />