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3V 5141P# Pl rA 761076._ 1111111 0 0 5 3 2 8 9 7 2 S K S Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number C'AD9,q3F 93x_,41 12.Page 1 of 3.1Emsgeyr,Ey.Resp0}se"P1PR 4.Manifest TNumber WASTE MANIFEST 1005'M972 SKS 5.Generator's Name and,Mailing Address Generator's Site Address(if different than mailing address) rii 1-OuBiJ S Rld CA '352.05-8010 2117193-946-0117,714 Generator's Phone: 6.Tran'spnrter'hComPPnY-Ve c•!h T-n, !r U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address C:;_ _ ;f'1 I1(tf{s';!; `.'e(3rti ;..:i_ ...!..-, U.S.EPA ID Number 1.001, BERRYESSA RCIIA.%? 08--441..-019,6 SAN J�7.193F CA r)711133 :,{'; t0•59494 10 Facility's Phone: 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. Z W •i r -�-,r } � 4 3. F ''',,,t 1?FiILIN . ti #TTI I fJILJ 9I I-bLX r-1 117.E)�BI(�'f tz•�_Jt't%t."1 I 71 Psoo MAR 3 20 6 4. EIV 14.Special Handling Instructions and Additional Information I b!),zIJ .;ii'. 1; 1i::'_'. '_,i•:;47t':_i` .c:i!T 1 ERS#171 2I'3R EME'14GENC:Y #1--800-468--1.7-60 (S-K i- TFI) Ft!}Ts{ FaC4 "A IFNIT-.FOR" BY �C31DI TO RETAIN LIC,I:NSED SUR C.-ARRI S FI' �N1=;:..E::;; AF1,1`'{ 15. GENERATOR'SIOFFEROR'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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable internati nal and national ental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowled nsent. I certi that the waste minimizaC n statement identified irt40 CFR 262.27(a)(if I am a large quantity ge ator)o (if I am a all qu generator)is true. Genera11 pe a Sign Mo Day Year � N ) R-It -J 1 16.International Shipments ZImport to U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Trans er Printedrryped Na Signature Month Day Year QTran orter 2 PrintedfTyped game Signature Month Day Year x`- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) UJI C 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year IPfferm8 r� R .13�O ous die o sto)ete �•, . } r Fe$I NATED FACILITY TO DESTINATION STATE(IF REQUIRED)