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M-,04--c 15 15:50 FROM- Cips Environmental 661-322-8883 0 T-454 P0005/0012 F-956 <br /> Please print of type.(Form desl ned for use on olile(12-pitch)typewriter.) - Fon proved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator 11)Number 2.Pago1 of a.Emergency Response Phone 4.Manirest Tracking Number <br /> WASTE MANIFI=ST � 9.450.045D 013435261 JJ K <br /> 5.Generators Name and Malling Address Genemloys Slle ArMAME(rdfferent than mailing address) <br /> PACIFIC SOUTFiWEW IRRIGATION <br /> 6372 S.dACKTON RD. <br /> STOCKTON,CA 95215 <br /> Genemlors Phone: <br /> 6,Trallspodar 1 Company Nadia VCLJ U.S.EPA ID Number <br /> George W. LOW7y,Inc. j C-ARMW47010 <br /> 7.Tmnspoller 2 Company Name APR 08 2015 U.S.EPAIDNumber <br /> s.b ado N man AAir rasa MEAT U.S.EPA ID Number <br /> ON619 S E Imo. ON M <br /> 11610 W 610 l7triStreet H CA 915513 HFA�TNOFPARTUIENA� <br /> Favaiys Phone: 000-627-6729 <br /> ga tib.U.S.DOT Description 0nduding Proper Shipping Name,Hazard Class,ID Number. 10.Conlamem 11.Total 12.Unit 13.Waste Codes <br /> HM and PaCHng Gmup 0211)) No. Type Quenfity, WtNal. <br /> 0 X UN 113.3 WASTE FLAMMABLE LIQUID It. o.S. (AdheSlueer) 3 P011 � DM .31 <br /> C' 17001 <br /> z 2. <br /> eD <br /> cb <br /> 3. <br /> 4. <br /> 14.Specter Hsndring InsW cions endAddidonal Intodsaficm <br /> USE GLOVES TePRODLE#&MelhylElhytKetone PVC pipe glue <br /> FII NVO I C IV RS-03 6 <br /> 15. GENERATOR'5fOFFEROR'S GERT1FICATION:I harebydedare Diet the canrents or Nis wnsigmnentamtullyand accundeydesedbed above by lha pmpershipping name,and are deesified,package6. <br /> marked andlabstedrplacarded,tand ars In all respects in propereonddan for Imnsportaceoang to applicable imemationeland national governmental regulations.if expodshipment and I em lhe.Vmary <br /> E(poder,(ce lIfy that Dhoaonteo(e of We consignment oenforin to the terms of line allached EFAAcknowledgmenlof Consent. <br /> I certify(hal the waste minimization stalamanlldendfied in 40 CFR 26227(x)(d1 am a large quandtygeneralorj or(b)(diem a small quanfilygan mcdoy)Is We. <br /> GknemloYdOHamrs Primedflyed Name Signature .. Month Day eat <br /> .� te.mismationalsNpmams <br /> W ❑Impodk U.G. El Export from U.S. Pod ofsntryfoldl: <br /> z Transporter sgnaidle gorexporwony): Dare leaving U.S.: <br /> ITTranspoderAdmoWedgmenl ofReeoiptof Materials <br /> 1. Transporturt Ie pedN Signature tAonN Day Yeer <br /> � D ay Year <br /> K Traresporter2 PMlad/Iype ams Signature Monty <br /> F– <br /> } to.Discrepancy <br /> 18e.Discrepancy Indication Spars El Spa ❑Type ❑Residue ❑Partial Rejection ❑Fug Rejection <br /> I <br /> Moniker Rurelenco Number. <br /> 10b.Aromatic Fadlily toy Generator) U.S.EPAID Number <br /> J <br /> ZS. <br /> ua.. Faclflr/s Phone. <br /> w 18c.Signature olAlomale Facility(or Gamest) Month Day Year <br /> t— <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for haaeudous mere treatment disposal,and recycling systema) <br /> �.Q <br /> 1. 2. 9. 4. <br /> 20.Designaled Faddly Orrneror Operator.Certification of tecs'ryl,f hazardous ma(edelecovered by the maldfesl 1 as noted In Item lea <br /> PdnledffypedName _ S nm re Month Day - est <br /> FPAForm D-22(Rev.3-D5) Previous edi6onsare obsolete. DESIGNATED FACILITY TO DE TINATION STATE(IF REQUIRED) <br />