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Please print or type.(Form designed for use on egte(12-pitch)typewriter.) MEWED APR 3 O 2014 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.GenerarorlD Number 2,RageTI;of 3.Emergency Response Phone 0.Manlfeathaaking Number <br /> 011 n 05664 JJ K <br /> 5.Generators Name and MallingAddress Generators Site Address(if different than malting address) <br /> Si'm Clwnical ccgx^;Fin: Stas e. ratcaD <br /> 2302 Carlin cuci- IOI O G rltk tnsi GT. <br /> Generators Phone: Sn3TAc??VVo.f'41 '^e-2sg QF8`z 4f _+ r es < <br /> 6.Transporter 1 Company Name U.B.EPA ID Number <br /> 1Fnri:1 Entir�Drm=ntxl p F.neF�>,tT n.Bn�?%,R'esf Sacramerte L'.4 F 91 C- ' 1" -e <br /> t TmnspoHer2 Company Name U.S.EPA ID Number <br /> .. 8.Designated Faulty Name and SitgM.dress__."___ - U.S EPAIDNumber <br /> - - - <br /> Rm'doLrr Hay Ravi <br /> 6426 Hay R(1ad <br /> Facititys Phone. 7014SI 3276 VacaTryllR.CA q.%R-x <br /> ga. ab U 5.DDT Description(ndutling Proper Shipp'ng Name,kleaard Class,ID Number, 10,Containers 11,Tate[ 12.Unit <br /> HM and Pudding Group up(Wa(Reny)) No. Type Quantity WLNoL 13 Waste Codes <br /> i <br /> R.Q..NA2212.ASBESTOS,Q FGIII <br /> z 2. <br /> 3. <br /> 4. <br /> 14 Spial Handling Instruct!aw ane AddlgolMl Inkrmalkn <br /> IPA ReO m 0L BAA(JkID;93'0 Ellis SErer1 <br /> &4f Francisco,CA V)4109,(415) 71-6660. A816"ot-R011e1al Regtitetnmt ' <br /> bOCIFR6I-(BRppl[d,.sWout x Ielmledl <br /> 15 GENERATOR'S/OFFEROR'8 CERfIFICATIDN:I hereby dectare that the contents of this cansignmentare filly and accumtetydesrnLedaboua by respects in proper condition far uncommon according to applicable the proper shipping name.aN are classified,packaged, <br /> tabeledlplacerded,and are in all intamatbnal and national goremmental regulations. <br /> marked and If exports e,a;e end I am the PrimaryExporter,I cerbty that Rte contents of this consignment conform to the terms of me attached EPA PArm ledgment ofCwrsem. <br /> I cemy that the waste minfm®eon statement Identified In 40 CFR 262,27(a)Of I am a large quantity ganeialor)a(bJ(rfl am a small quantity generator)is We. <br /> GeneramestOReerm's Pdm,ffryped Name Signature Month rDay Year <br /> 14x.17,J;zOV <br /> '-+ems <br /> J 18. mernimorial tmipments <br /> 2 ❑importlo US. ❑Export from U,S Port ofentryMml: <br /> Transporter signature(Por export.any): Date leaving U.S.: <br /> 17 LensponerAcknowledgment of Receipt of atedals <br /> T Mrl Pdrue a Signature Day Year <br /> yMonth <br /> ZTrans r2 Name Signature Month Day ear <br /> } 18.Dsscrepancy <br /> iBa.Discrepw3dti'•Indication Space ❑ amity ❑TYpa ❑Residue ❑Pastel Rejection ❑Full Rejection <br /> iBb.Alternate FactlRy(or Generator) Re@renes Number. U.S.EPA ID NImber <br /> J <br /> V - <br /> LL Facilitys Phone; <br /> Wo 18c.SignaNreofAlternme FaalHy(orGenerator <br /> Q Monty Day Year <br /> Z <br /> 19.Hasatdous Waste Report Management Mefhod Codes Oe.,codes for haamdooa waste treatment disposal,and recycling systems) <br /> 1 <br /> 20.D <br /> PrInde iyp dfadliry Owrreror Operetar.Certlflg8m ofrecelpt ofhazallousmatedals covered by the manliest except as mtedmitem l8a <br /> PdmetlRyped Name <br /> J �,,.- Signature Man Da Year <br /> Y <br /> EPA Fom1800-22(Rev,3-05) Previous editions are obsolete. A <br /> DESIGNATED FACILITY Tb GENERA <br />