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Please prim or type.(Form designed for use on elM 12-0ch)typew0w. Forrn Approved 0IMB No:2050-0039 <br /> UNIFURM liAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phu" 4.Magi feral Tracking Number <br /> WASTE MANIFEST {r A L C)Op 3*13 &1'06 i 415 3711-57147 014 813120 JJ K <br /> 5.Generator's Name and MofirpAd*m/ Generators She Address(if different than mailing address) <br /> G,)¢ ���-� � tAra.S�(Y t.wr.-•r`.fir <br /> S�0Ie/1 v <br /> Generato �l t. a. l�• L .w+� i { L A <br /> r's Phare: r <br /> a �t' ••'! �•i Spnf 1j t✓ .�ti <br /> 6.Transporter 1 Compaq U.S.EPA ID Nanber <br /> RAMIM ENVtttOMMENTAL SERVICES fW- CAM44W3-636 <br /> 7.Transporter 2 Comfy Now U.S.EPA ID Number <br /> 8.Des!gnatedFadiyttmad!IbAdbess FA,Pet0S eVAR0NNi-NTAL SERVICES INC. U.S.EPA ID Number CAC?Q44L�i35�5 <br /> 71,515 Som RIIIJER RD. <br /> 'kAYEST SACR.MEM�CA 95691 <br /> Facil' 9Phone:916,371-57747 <br /> ga. gh.U.S.DoT Description ociudrg Proper Sl wkv Name,Head Class,ID Number, 10.CoMai+ers 11.TOW 12.Unit 13.Waste Codes <br /> HM and Packing Grp(d any)) No. Type Quanfity WL/VOL <br /> I. f Ct4 RCCA HAZARDOUS �tAS tc UQUID (OILY WALT—cam') <br /> ac <br /> rl <br /> � Z { <br /> 4. <br /> 14.Special Handling inabucillons and Additional lr&mation J-/0 <br /> 981) ERC171 J <br /> FiANDLERS TO BE TRAWEp AND USE.APPROVED PPE. <br /> Eft. `ONTRA.C-2- : RAGA S,ENViRONMEttTAL SEPWr:S <br /> 15. GEER <br /> NATO R'S flit WCATtoN:'I hereby declare fret the contents of tick consignment ate and aaxratefy descerLed above by Ore proper shipping name,and are classified,palmaay r <br /> Vd <br /> marked and lebeledoUicarded,and are In al respects In proper.condltfon for transport according to applicable international and national govemmental regulations.If export shipment and I am She Primary <br /> Exporter,I certify VW the donlanfs of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> 1 car5ly Ural bre r�sle mirtgrdzaRon statement irl�rEfied M 40 CFR 26227{a)(d I am a large,quentity b){if f a a rNty generator)is true. <br /> akre Month Day Year <br /> � <br /> - <br /> �jt <br /> ❑Ynpat io U.S. ❑Export from :5. Port of antrylexit <br /> Date leaving U.S.: <br /> Trarrepmmt tdgnebre(fa e�anty): <br /> 1Z 17LLI . ransporler d Receipt of Materials tulordh Dam <br /> Transporter 1 PdnWyped Namef Signature ( S ff <br /> a v}"� `` onth Day Year <br /> QTransporter 2 Printed(ryped Name Sgnatre <br /> 18.Discrepancy <br /> 18a.Dtscrepancy indication Space ❑ OrrarrlAy Tye, ❑Residue ❑Parisi Rejection 00FLO Rejection <br /> r <br /> Menthol Reference Number. <br /> 18b.Alternate FaaSty(or C,enerator) U.S.EPA ID Number <br /> J <br /> ti Fadllly's Phone: Month Day Year <br /> Lo 1BaftnabireofAtternateFacilty(orGerrarator) <br /> ' a <br /> 4 Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste§aehnerrt,dtaposal,and recycling systems) <br /> C 1. � 4. <br /> 2. 3. <br /> 20.Designated Facility owner or Operator.Cert ficalion of receipt of hazardous materials covered by the manKest goo o as nded in Item 1 Be Yeaf <br /> Print yped Name Signature e <br /> � v c <br /> 1�A F S7 -22(Rev.3 )5f Previous edllib&are obsolete. DESIGNATED FACILITY TO GENERATOR <br />