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-Please print or type.(Form designed for use on elite(12-pitw,..ypewriter.)_ „ , Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDQUS 1;GeneretoriD,Number 2.Page 1 of 3.Emergency Response Phone 4 ManifestTracking Number <br /> WASTE MANIFEST C1 $?I # <br /> a, T B F <br /> Generator's Name and Mailing Address e+�x" p Generator's Site Address(if different than mailing address <br /> ..,.. T L. (3 i,C-S2,�f�. - lel _ ... <br /> 'F <br /> IMM T SCHULTE RD. <br /> TAY,CA 96377 <br /> Generator's Phone:-` <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> =" <br /> VHOP WARDS Bt W71ONS,INC 04 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number *. <br /> flDesignated Facility Name and Site Address U.S.EPA ID Number <br /> CORDOVA.,CA 96742 <br /> Fadlity's Phone: <br /> 9a. gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,la Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No;:, Type Quantity WtNol. <br /> O 1. <br /> HAZARDOUS.. <br /> L <br /> WASTE� <br /> ae �JJ. <br /> MMOTOR u 2. _ <br /> 3: _ <br /> 4:.,. .. <br /> 1 Speaal Handling Insfructions and Additional Information ,;. , , <br /> l l A- <br /> EMERGEHICY CONTACT:CHMSTINE SILVA r <br /> 15 GENERATOR SIOFFEROR'S CERTIFICATION:]he dedarp,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 Fand are in all,respects in proper•condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Eacporter 1,cerlify that the contents of this consignmenfconfonn m the fauns of the attaded EPAAcknowledgment of consent wW <br /> A *that fhe Wi3ite miniiii¢allon statement identikdd'in 40 CFR 262.27(a)('if I am a large quantity generator)or(b)(`if I am a small quantitygenerator)is true. ` <br /> Gene or Offerors Pnnted(fyped Name Si re _ Month Day Year <br /> � 16 Infemabonaf Shf merits _ . <br /> h � � P . �Import to U.S. ❑Export from U.S. Port ofentry/ezif:" ' � _ <br /> w` 17 TransporterAdmowledgment of Receipt of Materials <br /> Q�Transorter7 fedlT�ped erne 5ignattire Moth Day r <br /> Transporter 2 Printed/fyped Name , • . Signature Month Day Year <br /> Q _ , <br /> 18 f)ts=pancy <br /> 18a Discrepancy Indication Space +Quantity " O Type ❑Residue j ) <br /> 0 Partial Rejection ❑Full Re action <br /> Manifest Reference Number: <br /> 186 Alternate Facility;(or Generator) U.S.EPA ID,Number <br /> Facilitys t'hone: <br /> ut 18c.Sgfiature of Altemate Facility(or Generator) Month Day Year <br /> 1 Hazanfous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> o r2:-: ,, 3. Notice:New federal form. State of <br /> California requires generator to photocopy <br /> �0 Desi�nated:Fadiity Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a and mall t0 DTSC within 30 days: <br /> Pnnted/iyPed Name Signature P.O.Box 400,Sacramento,CA 95812-0400 <br /> ( ) _ — <br /> EPA Form$1110-22 Rev.3-05 Previous editions are obsolete. <br /> w, _ GEtdERATOR$S INITIAL COPT( <br />