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Fnrm Annrnvpd OMB No. 2050-0039 <br />GDA G- 07!10-19 IPav t_f1rl Prpvinuc editionc arR nhenlptp / <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />'�. s 1`' :S _ ' : S =; .' ! <br />2. Page 1 of; <br />3. Emergency ResPpnse�h�ne� �I,a ! <br />- <br />4. Manifest Tracking Number <br />G B F <br />WASTE MANIFEST <br />S. Generator's Name and Mailing Address I Till; t� `._:rL C : rr .)Iii. Generatorsl�S Qddr�)Ss (�f dieritl m�jli� g address) <br />xttewLjan, EnvTo-iffrientai rleaith & Satiec., ISTiO P7.cxli 2..sxt <br />5200 Shs:ila Strv:ct C"omnl r .c C a, 91.1040 Stockton, Ca. 952 15 <br />Generator's Phone 313) �6-� 5200\8 -' , <br />6. Transporter t Comp br . EPAIDt u r, f 7 y <br />illi. � BC#ui Filter Rtc cling : 11 � �U� .1 151 <br />RECEIVE Q <br />7. Transporter 2,Company Name .::: U.S. EPNID•Number <br />914 <br />8. Designated Facility Name and Site Address 1Z ;1:'t ? - U.S. EPA ID Number <br />1428 'r Lbl#13liiTiS. t tnlitil, t <, 'r 1 <br />ENVIRONMENTAL HEALTH C AL000102751 <br />( 5 9, 44 02:u) <br />DEPARTMENT <br />Facility's Phone: <br />9a <br />91b. 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 />WI.Nol. <br />1' c S , a "' r ; ti <br />L.iqui4 Oil) <br />(UsedOLf, .,ill Lir <br />I <br />W <br />Z <br />2.. <br />j <br />UJ <br />O <br />li <br />I <br />3. <br />+� <br />i <br />4. <br />I <br />14. Special Handling Instructions and Additional Information <br />fi'•..' 7' `3 31 % l n !'1'( .t31' Ml)s�s .. I,. iw +9 . �v 3`i4 C_�11 j';� 3110' lrl�3t? :1'$t�2iai .Protective <br />Equipment <br />i. <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratelydesuibed 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 intemational rid national governmental regulations. If export shipment and I am the Primary <br />iter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of CoD ent. <br />coy that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b)96 am a small qu ty ge erator) i rue. <br />/' <br />Ge,nerato ssiOfffeeroorA Prin yped ime Signature:.- Month Day Year <br />16. International Ship7tnts ❑ Export from U.S. Port of nt /exit: <br />❑ Import to U.S. P try/exit: <br />Transporter signature (for exports only): �/' Dat e. ng U.S.: <br />L <br />17. Transporter Acknowledgment of Receipt of Materials <br />O <br />Transport rinted[Typed N Signature ' Month Day Year <br />Z <br />a <br />Transporter 2Pr+�r t (Type _ Sign u Mont Day Ye r <br />�. <br />t18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) 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 />LU <br />1 <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 />PrintedlTyped Name Signature _ Month : ;Day <br />]Year <br />GDA G- 07!10-19 IPav t_f1rl Prpvinuc editionc arR nhenlptp / <br />