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,0 <br />Please Drint or tvr)e. (Form desidne Inir use nn AMP 1 nff(,. nAwritpir) <br />P— A— -A MAD kk lnrn-nillo <br />cr-m ruin otuu-Li knev. a-uD) rruvivus ecinions are ousoiete. <br />DE*GNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />11. Generator ID Number <br />2, Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST.., <br />I' CAL00j)j61953 <br />1wo-42*ww-cHwn=1 <br />006068662 JJK <br />5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) , <br />a & Ch SOLVTIONS IINC <br />107 VALVERVIN PKWY <br />61DMONItA 962M <br />Generator's Phon2011141V= <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />FRB40LW ENVIRONMEMAL SERVICES INC. RWO 0 80"W3274 CMOW171017 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address. <br />EIRGREJEN OIL , W, OX49- U.S. EPA ID Number <br />44W-RQA0AV4 4,950 Ili, CAM82"W4 <br />W a <br />F@cllft?s.Phone: 510 -"f95 -44W <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers11.Total <br />12. Unit <br />HM.gild <br />Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No.. <br />Type <br />1." <br />NW RCM HR=rdOw J*Ad(OILYWATER)4 bl4jf& <br />G <br />2M <br />LICA9 <br />LU <br />2. <br />L7 <br />4 <br />4. <br />14. Special Handling Instructiorrs and Additional Information <br />HWKWS tO bs 40 INOW kaftwd OW wow PPE <br />Obl) ERG # 171 <br />15. GENERATdR'S1OFFEROR'S 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 respects in proper condition for transport according to applicable international and national governmental regulations, If export sh ipmdn d I am the Primary <br />I , t <br />Exporter,. I certify that the contents of this consignment conform to the terms �of the attached EPAAcknoVAAedgment of Consent. <br />I certify that the waste-minimMon statement identified in 40 CFR 262.27(a) (if I am a large quantity generator (b)ffl I aq�rtity generator) is true. <br />Genbralors/Offe e P' ted/T ed N Month D Year <br />s nn V_harne Signa ay <br />1610" <br />-1 <br />I.- <br />16. ROMoii-al Shipmeffis%— <br />, Import to U.S. ❑ Expo m Port 6kwhoetr— <br />Transporteraignaturb (for exports only): Date leaving U.S.: <br />IX <br />Uj <br />17. Transporter Acknowledgment of Receipt of Materials <br />j2 <br />Transporter I Printed/Typed Name Signature Month Day Year <br />0 <br />- CL <br />co <br />1 ty C-7 C/ <br />Z <br />Transporter 2 Pddtgd/ ryped Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy indication Space El Quantity F]Type EI Residue EIPartial Rejection E]Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />M oc <br />Facility's Phone: <br />0 <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />C07 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item La <br />Printed/Typed Name Signature' MoItt"ki Year <br />rR ly YL <br />CA <br />b. <br />cr-m ruin otuu-Li knev. a-uD) rruvivus ecinions are ousoiete. <br />DE*GNATED FACILITY TO GENERATOR <br />