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Sep 26 11 1 D.T.S. 2r`9326175 p.4 <br /> Please irint or type.(Form designed for use on elite 12-pitch)typewriter.) F-ln Approved.OMB No.2050.0039 <br /> U IFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of]3.Emergency Response Phone 4.Manlfest T7aeking Number <br /> #ASTE MANIFEST A L 0 G 0 iJ 9 2 4 2 1 (POO) 424-9300 008816833 JJ K <br /> S.Generators Name and Mailing Address Generators Site Address;if different than mailing address) <br /> DIVINEY TRANsPoRTATION <br /> 515 i W. 11TH STREET r 11951 W, i I TH STREET <br /> TRACY CA 95075 TRACY CA 'W96 <br /> G erators Phone: 1,1 i <br /> 6.Iransportar i Company hiame U S.EPA ID Number <br /> i 1RONNENTAL SERIACES C A D 0 2 3 2 -1 7 0 3 6 <br /> 7.-ransperer 2 Company lame U.S.EPA ID Number <br /> 9.Designated Fac lity Name and SAe Address U.S.EPA ID Number <br /> SIENENS INDUSTRY, INC. <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES7747 C 90058 G A 0 0 9 7 0 3 0 9 9 3 <br /> Fa ilily's Phone MQ <br /> ga 91a.U.S DOT Desa ptim(including Proper SKI inc Name,Hazard Gass,ID Number, 1C.Containers 11,Tout 12 Unit <br /> HM and Packing Group(If any)) No. Type Cuartity Wt1Vol. 13.Waste Codes <br /> O <br /> N-RCRA HA7ARDOU5 WAST , SOLID(OILY SOLIDS) F n <br /> w <br /> i <br /> Z 2. <br /> U.1 <br /> 0 <br /> 3. <br /> 4. <br /> 14 Spacial Handling Instructions anc Additional Informali n <br /> NAERG# 9B1 : 171 "PR FILE#9P1 : OILY SOLIDS'EMERGENCY CONTACT. CH <br /> ENEIREC 1 SQO-d24 93U(7'ADDITIQNAL EPA <br /> C{?DES:9B1 . ,NONE`�PPROPE IIATE PERSONAL PROTECTIVE EOUIPIa�NT <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: h reby declare that the contents of this consicnment are fully and accurately descri-ed above by the proper shipping name,and are classified,packaged, <br /> marked and labeled(placarced,and are in ali respect in proper condition for transport accorcing"'applicable irtamational and national governmental regulations.If export sYpment end I am the Primary <br /> Exporter certify that the contents of this consignme t conforto the m terms of the attached EPA Acknawiedgment of Consent. <br /> f:erti y trial the waste minimizatfor statement identifi d ii 40 CFR 262.27(a)fif I am a large quantay generator)or!b)(if 1 am a sma9 quantity generator)is truer <br /> Ge raro'srCffe:ror's Printedri-yoed Name Si , lure ay Year <br /> eq <br /> 'e. ,wrational Shipments <br /> ❑Import to U.S. ❑Exccrtfrom US. Port ofertryrexlt <br /> i ra.-s;,crter signature(for exports only): Date leaving U.S.: <br /> '7 T.-arsponerAcknowledgmentYReceipt ofMaterials <br /> } nor i PinteclTyped Name Signature a' Y <br /> O <br /> 0 <br /> a. <br /> 2 'Aarisporler 2 Print ed dame on ,Month Day Year <br /> rr <br /> H <br /> 10.Discrepancy <br /> 18a{Cisaepancr Indicaton Space puantl7 U Type ❑Residua Pa tia Rejection ❑Full Reject:cn <br /> Manifest Reference Nurnber. <br /> 18b.Allemale Facility(or Generator! U.S.EPA ID qumber <br /> h <br /> J_ <br /> U <br /> uu- FaclMs Phone: <br /> LU 18c i5ignatura ofAl'emwe Facilily(or Generator} Month Day Year <br /> < <br /> a <br /> z <br /> i9.Hazalldcus`Waste Report Management Method Ccdes(i ,codes for hazardous waste Ireatmenl,disposal,and recycling systems) <br /> 0 1. 2. 3, 4. <br /> I <br /> 20.Desig ated Facility Cwner or Operator:Certification of re ipt of haza•dous materials covered by the manifest except as acted in Item 18a <br /> �rinledff ed Name Signature IulOnrh Day Year <br /> EPA Form 8? 0.22;Rev.3-05i Previous editions are obs ell �SIG);-i4, HOL,, 0 1L:71 TC DESS t;:j-?GN MTA;";^= �?G01:1!R E0) <br />