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- _ -__ _ � III!I�f�lll�l�l��181111111ll� <br /> 'n Please print or type.(Formtlesi- ruse on elde(12-pitch) .) "- Form Approved.OMS No.2050-0039 <br /> UNIFOO HAZARDOUS- -"Generator ID Number 2.Pace i of3.Emergency Response Phone 4.Manflast TrxFing Number <br /> WASTE MANIFEST_-_ -_ 6 2 4 1 0 1 0 -+-'a !8771 81&0067 000543499 VES <br /> S.GenerelWs Name arid Ma3rg Address pp qqccqq� Geneting rators Silo Address dimment than maaddress)" '" ' • <br /> _ _ --- 4%5QAVA'�SLANE SAME <br /> STOCKTON,CA 95206 <br /> Generamrsvhone:209 48a-B01.4 <br /> 6.Transporter l Company Name U.S.EPA IDNunber <br /> VEQI14.ES TECHNICAL SOWTICN S N J D 0 B 0 B 3 1 3 B 9 <br /> 7.Traspoms 2 Cmgcmy Name U.S.EPAID Number <br /> MP ENVIRONMENTAL-SERVICES C A T 10 0 0 5, 2 4 2 4 7 <br /> 8.Designated Fatally Name and Site Address U.S.EPA ID Number <br /> VEOLIA ES TECHNICAL SOLUTIONS <br /> --- 1.704 W.FIRST STREET <br /> FadrO'a Phase: 628 AZUSA.CA 91702 C A O -4 6 8 3 0 2 8 0 3 <br /> 10,Containers <br /> ga. 9b.U.S.DOT Description(ndWinProperPer Shipping Na .Hazard Class.ID Number, 11.Tod 1z Unit 13.Waste Codes <br /> HM and Pading Group(p any)) No. Type OUNMY WtNU. <br /> NnN-RC'RA.HAZARQOUS'VASTE UQU(D,(INK SLIDGE1 491 <br /> 0 0 0 1 D M 0 0460 P — <br /> w zJJON-RCRA HAZARDOUS WASTE SOLID.ANX SOLIDS) 352 <br /> 0 0 2 D M 00591 P <br /> 3. <br /> i <br /> 4 <br /> i <br /> 14.Spacial Handling Inabuctions and Additional hdormabon ER Service Contracted bV VESTS <br /> -I,- 11 W 10083 A:REC-WATERND6iA)1 K 55(BAL 2)W 10082 A:AZU-DEBiFUEUNS 2 X 55GAL <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this ,von and are holy and accuraley described above by the proper shipping name,and are classified,packaged, <br /> marked and lebetedlptamnied,and are n ad respects in limper coroll"for transport acmdmg to applicable international and national govammemal regulations.If arport shipment and I am the Primary <br /> Exporter,I m41y that the contemn of this mnagnment conform to the terns of the alladesd EPAAdapWRdgment of Consent. <br /> I pettily M the x-vsR mmimvation eauml rd&d fried in 40 CFR 262.27(x)(fI am a large quaraty generawr)ar @)(rfl am a sma4 quanidy gnM is ma. <br /> Gererabral es Printedyi Name Month Day Year <br /> 0 4 2 4 2 <br /> 16Nterationa Shipments Ll import to U.S. El Export from U.S. Port of arNyhedt <br /> = TransWrlar signaturs(for exports ordy): Datta leaving U.S.: <br /> W 17.Transporter AdWw1Od9naidef Receipt d MaReiak Month .Day Year <br /> transporter 1 Pdnledfryped Name Signal <br /> d FREDNAESEMAN 0 4 12 9 P 2 <br /> = <br /> TransWner2 P' yped Name WSigraW �1 — y Day Year <br /> of IF ✓� r✓cS D7 t.7 J L <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Spare ❑ Ouanfiry ❑Type ❑Residue ❑Partial Rejx9on ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Abemale FacI4(or Generatorl U.S.EPA to Number <br /> J <br /> U <br /> LL Facenys Pham: <br /> w 1S.-Siwe afAllertale Fadlily(or Cx ratorl Mahn Day Yaar <br /> Q <br /> 2 <br /> h19. Waste Report Management Method Codes i.e. cedes for hazardouswaste treatment disposal,and recycling systems) <br /> W 1 Mhagd= <br /> 3. 4. <br /> 20.Designated F or Operabr.Certificatiols covered by Bre i except as road in Nem ye <br /> Pwi yped Si / '� Y. <br /> EPAFam8706-22(kw.-3t5) Previous i0onsamobsolete. DESIG LITYToDESTINATI STATE(IF REQUIRED) <br />