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Ploaco nrint nr fimo /Fnrm riacinnarl fnr i ico nn olito 119-nitrhl fimawrihlr 1 <br />Z <br />Form Aooroved. OMB No. 2050-0039 <br />-Jf I-,- 07nn nn 10-, 9 nri O-Annd gra nhcnlata <br />UNIFORM HAZARDOUS <br />1. Generator ID Number + ) ' � s2 5 1 <br />{.•� ��-��'� �.��iw .� � <br />2. Page 1' of <br />13. EmergencTy JespSry (08044. D --`UR <br />4. Manifest Tracking Number <br />G B F <br />WASTE MANIFEST <br />5. Generator's: Name and Mailing Address ,. Generator'siSitp E i res (if i,. a t.b mai i address) <br />, s, a .t . . a,sl.. s1 ,, 4�c . <br />�` <br />ni )+Ln Health'�lp"C, <br />l�'yy. r"111{+(+.���ry/-511.,,A.//nuelu'l Health <br />}(W�1�fI�� y� �" L <br />IM`.r"�VSA:fA •l i$iL1 tv�l.liCi1�b1 MWi'�1•{y. <br />NM <br />GeneratorsPhohe' J. � 3 ? -i•- •=:7 ti?tlLr RE <br />NN D Num e � <br />6:.Transporter 1 Compan . , a e ; ^, `R ,.` �t <br /><3 JCr, quin F I er.Rv i� 11Si - <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />Number <br />8. Designated Facility Name and Site Address VI RO N M ENTAL H E ALV <br />Safi Joaquiti Wartier Facifity <br />DEPARTMENT <br />14-137 E. Manning Parker, CA. 93.48 <br />1 <br />i ti -.iu t - ;r l_ .�LU001.0-731 <br />Facility's Phone: <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />7') <br />Liquid 4d oili i irt ()ilk <br />i <br />-r-1 (� <br />1 <br />Z <br />2. <br />w <br />c� <br />3. <br />4. <br />14: Special Handling Instructions a{{nd Additional Information <br />y <br />. Used <br />9 ? �. %�. k' fl i1�s 1Chil�i01 Mixed *Appropriate Personal Protective <br />Equipnwnt <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents 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 in 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 qua tity generator) is true. <br />Generators/Offerors P in edlType ame %� / Signature �.:p_ .., Month Day Year <br />-1 <br />r- <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />K <br />Transporter signature (for exports only): bete ledvl>g S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />O <br />/ Mon Year <br />Transporter 1 Erinjgd yped me Signature Month Day e <br />Z <br />Transporter 2 Printed/Typed Urffe , Signature.,: ' Month Day Year <br />W <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID <br />Q' <br />Faahtys Phone: 9P <br />w <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />� <br />1 <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature i Month Day Year <br />-Jf I-,- 07nn nn 10-, 9 nri O-Annd gra nhcnlata <br />