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IIIIIIIIIiIIIIIIIIIIIIIIIII1111111111111111111111111�1�1111111IIIIII <br /> Please print or .(Form d - "ed for use on elite 12--pkh)typewriter Form Approved.OMB No.205044 <br /> UNIFORM HAZARDOUS 1.Generator ID Number ]2.Page 1 of 3.Emergency Response phone 4.M&MW—T <br /> WASTE MANIFEST . CAT000610949 2 (800).326-1221 77 d 2WAS <br /> °B'lRACY1 DAN PEREZ Sit �' _ ) DAN PEREZ <br /> 400'WEST�VALPICO ROAD—SITE404 WEST VALPICO ROAD—SITE <br /> TRACY, CA 95376 TRACY CA 95376 <br /> (209)836-1971GEN: 4495 <br /> Generator's Phone: <br /> Company ams U.S.EPA ID Number <br /> HERITAGE TRANSPORT, LLC / SIGNAL HILL IND058484114 <br /> 7.Transporter 2 Cw"rry Name U.S.EPA ID Number <br /> HRNTAL SERVICES LLC U.S.EPA ID Number <br /> 284 E STOREY RD AZD081705402 <br /> COOLIDGE, AZ 65228 <br /> Face s Phone: (520)723-4167 <br /> 9a I 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Numiber, 1o.containers11.Total 12.Unit <br /> and Packing Group(W any)} 13.Waste Codes <br /> HM No. Type Duan ly m1w. <br /> a K 1. RUIUN1950 WASTE AEROSOLS FLAMMABLE, D001 513 <br /> N.O.S. ,2. It (FAINT), (D0011,EhG�#26 ( 25 P <br /> ru X 2' RD NA3077 HAZARDOUS WASTE SOLID, N, .S. , !I D0t7 <br /> 9,PGI)I, (MER�URY), (0009),ERr,4171 I -7 P <br /> 3. NON RCRA HAZARDOUS WASTE SOLID (OILY 22 <br /> ABSORBENTS) , 1 <br /> (IDM,19@ <br /> 4. NON RCRA HAZARDOUS WASTE SOLID (OIL .��^ P4- <br /> 141SPOHjftl' <br /> FILTERS) wo,� CID&25)l �� 2 2�I { 258 9 LDR 3.W2_Q53 299 4.W3QW?� <br /> f r � � om m � <br /> [1390504]GT <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acwrately described above by the proper shipping name,and are cissailled,padtaped, <br /> marked and lebeladlptacwcW,and are in of respects In proper condition for transport aocordkg to applicable it+tartrelional and national I regulations.If export shipment and I am the Primary <br /> Exporter,i Certify that the contents of this consignmentoorrbrm to"terms the attached Ei'AAcknoegrtle <br /> dedntf <br /> o <br /> I Dandily the[the waste mi nketzatonh statement idended in 40 CFR 262.27(a)('d I am a large quantity generator)or(b) 1 q=is true. <br /> Generawsoftfor's NdTVW Name tilgnature <br /> year <br /> 9' WA-rsiou—i 1 17z o <br /> J 16. ❑Import to U.S. ❑Expod fiam U Port of entrylewt <br /> T fnx on Date kmMng U.S.; <br /> 1 T,T of Receipt of <br /> bre <br /> wsp� `C� rear <br /> 18.Discrepancy <br /> 189.Discrepancy Indication Space ❑ Quantity [—]Type ❑Residue ❑PartW Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> F s Phone: <br /> aa 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> . Y <br /> 19.Hazardous Wasle Report Management Method Codes(I.e.,codes for[hazardous*este treatment,disposal,and recyding systems) <br /> H141 z. H141 3. H141 4. H141 <br /> 20.Designated Facility Owner or Operator.Cedifiration of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> NntedfTyped Name Signature Month Day Year <br /> EPA Form 870x22(Rev.3-05) previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />