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'—� 'ch) tv <br />Please print or type. (Form designed for use on elite (12 -pitch) ty ewriter) . 2 Pages <br />1. Generator ID Number <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />5. Generators Name and Mailing Address L + a� <br />a_,eritioa::n'r iri +rtYnia�. r1 1th SaYe� , <br />52011 Sheila Str;I�t Coln=nesse Ca. 90,04 i , <br />f 323, ',a-t-52()�:Lnii=i3 <br />Generator's Phone: ' <br />6.Transporter1CompaW-111P.-kii-Iii1 I <br />7. Transporter 2 Company name <br />8. Designated Facility Name and Site Address <br />F2—. <br />cription (including Proper Shipping Name, Hazard Class, ID Number, <br />p (if an r r <br />0��sizz <br />UJ <br />Equipment <br />Form Approved. OMB No. 2050-0039 <br />ng Number <br />iQ,wZ9A; GBF <br />19Qi;F'sscoli R_iac! <br />Stockton, Ca. 4521: <br />U.S. EPA ID Number <br />C A,L000 102 5, i <br />10. Containers 11. Total 12. Unit 13, Waste Codes <br />No. Type Quantity Wt.Nol. <br />1 <br />i <br />JU 28 014 <br />ENVI ON LTH <br />and are packaged, <br />y and <br />ly described above by the proper <br />15. GENERATOR'SIOFFEROR'SCERTIFICATION: lin yeacondtion frrtransport act the contents of lcord ng9oapplicable inment are nternational national and national governmental regulations. If export shipmeping name, nt nd I am the Primary <br />marked and labeled/placarded, and are in all respectsproper <br />if I am a s all quaptity generator) is true. <br />if I am a large quantity Month Day Ye <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) (Signaturor (b) e <br />Generatoeslofferoes PrintedlTypt:! Name <br />V rPort of antrylexit: <br />.j 16. Intemational Shipments Import to U.S. ❑Export from U.S. <br />Date leaving U.S.: <br />Z <br />Transporter signature (for exports only): <br />W 17. Transporter Acknowledgment of Receipt —Materials Month Day Y, <br />Signature <br />Transporter 1 PhntedlTyped Name <br />a s Month Day Y <br />Signat <br />QTransporter 2 PrintedlTyped Name <br />H <br />18. Discrepancy❑ Full Rejection <br />18a. Discrepancy Indication Space El Quantity ❑Type <br />❑Residue ❑ Partial Rejection <br />Manifest Reference Number: <br />U.S. EPA ID Number <br />181b. Alternate Facility (or Generator) <br />J <br />v Month Day <br />Facility's Phone: <br />W 18c. Signature of Alternate Facility (or Generator) <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disp3sal, and recycling systems)4 <br />Month Day <br />20. Designated Facility Own r or Operator: Ce Irication f receipt of hazardous materials covered by the ms gnaturecept as noted n Item 18a <br />��� • , <br />I ' <br />Prinled(fyped Name f%� '` ,,�•''� � "' �� <br />