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Please print or Woe. (Form desianed for use on elite (12-eitch0riter.) <br />is Form Approved. OMB No. 2050-0039 <br />EPA Form18105227ev'3-0"reTious edltas'dreb6selete. <br />DESIGNATED FACILITY TO DESTIRAMN STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />CALOOO194471 <br />2. Page 1 of <br />1 <br />3.Emergency Response Phone <br />866-333-9222 <br />14. Manifest Tracking Number <br />003930714 <br />WASTE MANIFEST <br />FL E <br />S T&e -Ir-ss Na.j a�a�lljg_AddrIV.Ste Sersices Inc Generator's Site Address (it different than mailing address) <br />1333 E Turner Rd - <br />Lodi, Cu. 95240 <br />Generators Phone: 9110 741 5611 <br />B. Transporter 1 Company Name U.S. EPA ID Number <br />Adranoed Chemical Transport CAR00007O54O <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. <br />p�1� <br />8. 6%nanated.Eaoh1Na@paste greesMgNent U.S. EPA 10 Number <br />uea <br />35251 Old Skyline load <br />Kettletan City, CA 93239 <br />Facility's Phone: 559-386-9711 CATOOO646117 <br />gra <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt Nol. <br />1, Ron asaz pus waste, Sol (013[y o i <br />3.921 <br />Dill <br />P <br />Z <br />W <br />2. <br />1 <br />3. <br />1 <br />4. <br />14. Special Handling Instructions and Additional Information <br />1) CA6OO162; CEC- Ot -003u/�/r <br />Project limber: ICVO1936 -03 <br />15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respells in proper condition for transport according to applicable intermational and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the tens of the allached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identfied in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />AsnaQtoesl0terorsnot yped Name r9n on ay Year <br />%-# of i � l <br />F6. <br />International Shipments ❑Import to U. S. ❑Export from .. Part of entry/exit: <br />Transporter si nature for ex ods and : Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Trans realrintedRypedbi Signatu ont ay Year <br />Xz-I <br />QTransporter <br />2 Printed7fyped Name /51gnature Doth Day ear <br />K <br />t - <br />y. <br />18. Discrepancy <br />18a. Discrepancy Indication Space DO ... fly El Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility(or Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />Fadli 's Phone: <br />w <br />18c. Signature ofAltemate Faulty (or Generator) Month Day Year <br />a <br />Z <br />a -i <br />19. Hazardous Waste Result Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2. 3. <br />4, <br />20. Desi at Facilt er peratoe Certification of receipt of hazardous maledals covered byth este noted in Item 18a <br />Pain y dNa Sign r n a Yea <br />EPA Form18105227ev'3-0"reTious edltas'dreb6selete. <br />DESIGNATED FACILITY TO DESTIRAMN STATE (IF REQUIRED) <br />