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3 <br />Sep 14 2015 10:45AM HP FaxLadds Marina 2094779585 page 4 <br />.rasa-rl=rQI"KI'L01 <br />" 1 'V=JUP4A1hIJ FACILITYTO GE!4EFJAT0A. <br />Plow <br />rM <br />;rJ1•ed for 4nRe 12 <br />Ouse on e <br />Form Approved. OMB No. 20540039 <br />WNW 01J6 i 1. tor 0 Number 4.N Res Phone <br />se i-Z� II , <br />E IFEST : <br />I4.0IMan <br />7rWA <br />2i 4g <br />5. 22 SSe Name and Malik Address 4K <br />2 <br />n <br />Ladds M4tyina patricia Bennifi1 anmalingadaressS <br />eld <br />4911 BuLchlpy Cave Way <br />Stockton CA 952104—a <br />Generator's Phone:SEP 14 201-5 <br />SYBTEMS, INC. U.S. EPA DNIumber <br />MENTAd <br />?. Transpo;et Coripeny NoMa <br />jJC!fA1-'J r)C0j0TRAChjj U.S, EPAID NurnbiTr' <br />Destria7d MMY NaMV 9W Site AJdrees <br />LIU HARBORS BAk J08it L <br />1102 1 RRYESSA ROO <br />-10 408-441-81*P JrNE CA 95133 <br />FaIdM i's Phcr*: <br />9a. 9b. U.S. DOT Descriplion (including Proper Shipping Name, Hazard Class, ID %7t.&r, C�ontaunars; <br />it. <br />HM and Padang Group (ff arry)) No. Type Quan*y n1vol, Total 12. Unit 13. Waste Codas <br />VW77 HAZORDOUS WASTE, SOLID, N. t7.9, CF P I*M 0007 <br />fi-EAL, BARIUM), <br />9, time <br />4. <br />14. SpeciW HPIP9 I;M�, fend Infowtion <br />T3D.J LAP -8534 <br />e4 HR EMER 6F <br />.NCY Sf-WETY—KLEE <br />PA)THORIZED TO RETAIN LICENISED SUBSEQUENT CARRIFRS <br />15. GENERATOR'S,'OFFEROWS CERTIFICATION: I hereby declare that tne oontents; of the consignment are fuly and accurgialvdasoribed above by the proper shipping name, ra, am are dwifed, packaged <br />marked and laboledi'placarded, aM are in all respects, in proper condition for transport <br />according to applicable nm and n6cria] groyanmental regulations. If Wrl shipTient and I am** Primary <br />Exporter, certify that :he contents of this ools9nmOnt conform to the terms of the attached EPAAcknowledguniant of Consent <br />looMIthaltowaste minimization siatemeOldentiWin4DCFR :2.Z(a)(if I Orr a largeqLmVtygenera kVo( 0) (if I am a small quantity gener-atDr) is Inje <br />ktY <br />sr nth ear;1/j 004 <br />i - <br />16. hirnational sihipments A 42 <br />irrip"I b L.& ❑ EKpw ft" U.S. Port <br />of ent*)dt: — <br />Tramporter signature (for o� pons only) :--- <br />Date leaving U.S.: <br />Itz <br />17. TranspoMAcknovAedgmenI of R*ceipt of MaterialsLLI <br />I.- <br />TrWsPurylfrintedrTypeod Na Signatura <br />n <br />Mort Yee <br />V <br />f7 <br />Trenspo 2 Pr! hteCypod Name Signetxe Month Day Year <br />187e.ftnipricy:Wlicailon Space L] Quartty❑ Residue L Parm mod, ❑ <br />Full Rejection <br />Manifest Rellerarre Number1110. Altamaha Facif ly (or Generator). <br />U.&EPA IPMEnber <br />FaOVIsPhone: <br />18c.Slg(teiaeo`Al;emeteF or Gene <br />Month Day year <br />19 HilMrfts4fZblort ReportManagement Codes (i.e., codes for hazardous waste treatment, dimOowl, and recycling systems) <br />U <br />4. <br />. Deslgnat FaCiMy Omer or Dporalcir Cerlificatjon of rfteiptf.,Z;d a materials covered by the mandiast "as noled in Ilam 18a <br />Bled Name <br />Mont Day <br />:P6 <br />FWD UK-221FIev. 3-05) Previous ecMvq am nhripip <br />.rasa-rl=rQI"KI'L01 <br />" 1 'V=JUP4A1hIJ FACILITYTO GE!4EFJAT0A. <br />