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Farm Aooroved. OMB No. 2050-0039 <br />nada: <br />piim ui gyu. IFvini uasiy"u <br />UNIFORM HAZAt�'DOUS <br />iui uau W --R --r,,, J '1N..... , .. <br />1. Generator ID Numbed <br />ene <br />2. Page 1 of, <br />3. EmergencX Responseff-h ne.. _ <br />} # <br />14. Manifest Tracking Number <br />6 F <br />WASTE MANIFEST <br />`' <br />w...1 .:O <br />0013874 G <br />5. Generators Name and Mailing Address Generator Site �ddregs l f different than mailing adress <br />si% 41: f_7TC?ti;::Z5, t)i �:fii i t, _Tif>t 3iS 1114. <br />5?oG Stwila Strci:it Ccora rls iz: C ii. W04 Stockton. C;a. 95215 <br />Generator's Phone: ; 171", ?m 5"' c (': <br />6. Transporter 1 Compagy Nam U.S. EPA ID Nu aer. <br />:pan Joaquin kilter R.ec��c1M_ gt)U01+ 2751 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and SiteAddrM ,)()aCltlltl alllCa' is JQ.10,tt' U.S. EPA ID Number <br />1;14210171E,Mallni,-1g. l'arliar, '~CA. 3.�.�?t 43 <br />j ` <br />; Y,1Vi _la;:�'fJ_-I,J Ci" L j0 ilU_r 151 <br />Facility's Phone: <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12, Unit 13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />' <br />ae <br />1. .�ti �.. t:�\ 1',.. - F, .. � �. 1at<;, 3.1 i.=� `i.i:? •yet. ,� ,...- <br />1 <br />� ` <br />Ca <br />o <br />L.igtuid (1 sed C.)ikMixod Oil) <br />/0�p <br />- <br />ZREEz. <br />A.OF I V it: <br />3. <br />1 J 11L.-.4 LIS--+-. <br />4. <br />VIR NME TAL <br />AR ME T' <br />14. Special Handling In€tFu ns rldgit nal I1pforr�atyrof 4` pTOtIle_ '. } 1 -Used --Oil ' iiXed tail '� Appropriate Ter1onal, Protectilr:e <br />J. <br />Equipment-: <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and urately described above by the proper shipping name, and are classified, packaged, <br />marked and Iabeledlplacarded, and are in all respects in proper condition for transport according to applicable mational 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 EPAAcknowled ent of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) of (67.(if I am a small quantity generator) is true. <br />q ed Name Signature' ++ Month Day Year <br />Generatof � (fer is Printedfiypt , j <br />n',� • � � , f <br />t ,C� � <br />FJ- <br />International16!Shipments ®Import to U.S. ❑ xpo from U. D(t of a tt�ylexit: <br />Z <br />Transporter signature (for exports only): D leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Month Day Year <br />11,_Tran <br />ry 1PrintedlT ame Signatu f'�i <br />,y <br />r f. rSi <br />U) <br />Q <br />It <br />Transporter 2 Printed/Typed Name/ Si nature J Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ElQuantity ElType ❑ Residue ❑Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Facility's Phone: <br />Month Day Year <br />W 18c. Signature of Alternate Facility (or Generator) <br />Q <br />Z <br />rn19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1 • I 2. 3. 4. <br />20. Desjgnated Facility Owner or OperatorXertification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />signature " - Month Day Year <br />Printed/Typed Name,., <br />L:. _ N �, Q <br />014 <br />