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{7.7-V1 - - DT.j�t�.. Ori:6.8.5 146,6 <br /> `' _Please print or type; Form des' ned for use on elite(12-01bch)typewriter.).. Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> c. cAz;A0Q273454 -802-468-1760 001216825 SK$ <br /> WASTE MANIFEST �+ <br /> 5.Generators Name and Magurg Address ` Generators Site Address(If different than maEng address) t <br /> VILLAGE AST MARINA <br /> 6649. CHBARCADIEW <br /> STOCKTON _ CA 95.219 <br /> Generator's Phone:: US:9 SIP-ISS 1 - - -- - <br /> B.Trams 1 Co Name 1l• ~4 U.S.EPA ID Number <br /> SAMBT,IrTEEN sYA-ZX-S; INC. TXR000056030� <br /> 7.Transporter 2 Comparry atria = U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address INC:. 0 "618 U.S.EPA ID Number <br /> SAFETY-RLIrEN SYSTEI'4S, <br /> ' 1722 C00PER CREEK RORD <br /> DENTON, T. 76208 <br /> 940-483-5200 ;' TXD077603371 <br /> FadliVs Phone: ; r` .4 !; <br /> 9b.U.S.DOT (Including r Shipping Name Hazard ID Number ftif Containers <br /> Class <br /> ga, - Oescxgrtoan f �"9?roPa. 'PPN9 i1.Total 12.Urdt <br /> and Padd Group(ff any)) - 13.Waste Codes <br /> HM r9 � i •..W. Type Quantity wt.No1. <br /> Dana <br /> w _2 WASTE SOLIDS CONTAINING rLANHABLE. DFS P 'FOO row D001 <br /> LIQUID.-. N.O.S. (TOLUEMMETHYL ETHYL <br /> KETONE) 4. 1 UN3175 PG II �Q D03 352 OUTS <br /> 3. <br /> Oak-41AMem <br /> "Ilk <br /> 14.speaatHarding in�and Additional Information 'SK:.TRCK.;'#10.9593.105.. , •00.0253$59.8. __ <br /> 0 U. E. SUB609ZNT ° R IERS.'41078, '41471,81r681.8273'9. i. <br /> 15. -GENERATOR'SJOFFEROR'S CERTIRCATION:�hereby eby declare that the contents of this consignment are hilly and aoevraWy described above by proper shipping name,and are dessiflo.packaged, <br /> ed; <br /> mOW end tsbeledlpiscasdacid are respects in respin proper co4ditian fortransport a000rcing to applicable intematlanal acrd natural govemmental regrdattre.If export shtpment arta I am the Primary <br /> Exporter;I wrtify that tine contents of iA condipviient conform to the terns of the attached EPAAclmoxdedgment of Catsent. L <br /> s. <br /> I cer*that.the waste minimization slatameM Wormed in 40 CFR 262.27(a)(if I am a large gwr*generator)or(6)('rf I am a small quantity generator)is hue. <br /> Generetors101tara s PrintedfTyped Name Signature Month Day Year <br /> -j 16.International Shipmimis �:. <br /> Impart to U.S. Export from U. . Port <br /> ❑ of ent;Iexit: r <br /> Transporter signature(for exports only}: ` Data laaving'U.S:. <br /> d' 17.TranporOarAcfleriowledgmentdRecdptafMate6als <br /> Transfix, niedlTyped Name Signature Month dray, Year <br /> d , <br /> Q Transporter 2' yped Na Si �,. MonthDay Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SPaae C1 Quantity ElType ❑Residue 11Partial Rejection Q Fut!Rejection <br /> Manifest Reference Number: <br /> 18b.Altematb Facility(or Generator) U.S.EPAID NumbeY.14 <br /> FagTntye Phone / 't *• _ <br /> 18c.Signature of Alternate Faptity(or Generator) k hAcntYr Day YNT <br /> Z <br /> y19.Hazardous Wasta Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposN,and recycfmg systems) , <br /> G 1. T <br /> 3. 4. <br /> twa 1i <br /> 20:Des grpted Feo ty Oymar or Operator.dedication of receipt of hazardous materials oovered by the manifest except as rated in Item 18a <br /> Prl ypedN7, S' fJuggtln ':Dayft <br /> s <br /> g�L47 <br /> �, aim=406111L <br /> ) Pre' us ed" a to DESIGNATED FACILITYTO GENERATOR STATE(IF REQUIRED) <br /> 0506 3 4) <br /> 21200092680/40110432.482 - <br />