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Please print or type. (Form desioned for use on 4itp 112-nitnhl tvnowrttor 1 <br />111u « t—. ryuu� ewuuiu are usoieke. DESIGNATED FACILITY TO GENERATOR <br />- <br />UNIFORM HAZARDOUS 1 Generator ID f umber <br />- r-onnApproved. UMH No. 2050-0039 <br />2. Page 1 of 3. Emergency Response Phone 4. Manifest Trackin <br />WASTE MANIFEST <br />QNumber <br />J J 6 6 JJ K <br />Address <br />5. Generators Name and fda et %- r <br />%L t1 t U 11 ft I-1 f. ' <br />Generator's Site Address (if different than mailing address) <br />1 ! k: '' f <br />t O A i L.. 1i1 + <br />C <br />1 CCS�Gv��{ct <br />5+cert` b�3 EJB''' S+t(.-(- r <br />Generator's Phone: <br />, K t U /) (`) 2Xk) <br />6. TraWclrgraz,i1 G�TPPXMR9;;U INC <br />U.S` EPA ID Number <br />X13 <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facjlity Name and Site Address <br />U.S. EPA ID Number <br />6425 MAY I . <br />VACAVILLE, V.A 611 <br />Facility's Phone: X07-451,3276 <br />9a. <br />9b. U.S. DOT Description (including Prope Shipping <br />Name. Hazard Class, ID Number, <br />10. Containers <br />11 Total <br />12. Unit <br />HM <br />and Packing Group ('rf any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />O <br />1. <br />Z <br />0 <br />2.sa� <br />-rsz J Asa <br />3. <br />i Cil <br />4.-ENVIP' <br />r '4 <br />ITE=°JAR i MEN <br />i <br />14. Special Handling Instructions and Additional Infoi <br />naUon <br />ASBESTO$ REMOVAL <br />-1-RENT 4Ui;fR61 (BAGGED. SEALED, b LAfIEtfo) :j ..I Z le, <br />1 <br />FRL+?BLE ASSESTM Lr�tlal <br />1:3 MATERA!_ (TaAERG#171) 12 4WE&E W CAPE C)L Ai W. SA 800-42.15232 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATIO : <br />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 re <br />pects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consi <br />ment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement i <br />ntified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generatofs/Offeror`s Printedlfyped Name <br />�'V" �i �,l V`r/ (k V( t.-, <br />Signature _ , Mo Da jYeaarr <br />���� �� � � � �� N ,i l''t : {-L%�._. � � F ✓ <br />� <br />1= <br />16. International Shipments <br />❑ Import to <br />S. ❑ Export from U.S. Port of entry/exlt <br />Z <br />Transporter signature for exports only): P 9 ( Po y): <br />Date leaving U.S.: <br />LM <br />17. Transporter Acknowledgment of Receipt of Material <br />OTransporter <br />1 Printed/Typed Name <br />Signature Month D7ayy Year <br />a <br />13 <br />LA <br />ZZ <br />Transpcder2 PrintedlTyped Name <br />Signature Month Day Year <br />1- <br />18. Discreparicy <br />18a. Discrepancy Indicafion Space ❑ Quan' <br />❑ Type ❑ ❑ <br />Residue Partial Rejection <br />Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />_J <br />0 <br />W <br />LU <br />Facility's Phone: <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Method C <br />(i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />UJ <br />1 2• <br />3. <br />4. <br />20. Desigriated Facility Owner or Operator: Certification <br />of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />frnA <br />Pnnterl/Typed Name <br />Signature Month Day Ye# -11 <br />111u « t—. ryuu� ewuuiu are usoieke. DESIGNATED FACILITY TO GENERATOR <br />