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I <br /> � <br /> ' t <br /> o m designed for use on elite(12-pitch)typewriter.} Form Approved.OM8 0:05�p 0 39� <br /> 1TAROOtJS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> 1hANiFES7 CAL000273993 9 800 633-825 017090461 JJK <br /> Ynrs�a�nnrznd Maing Addrgs Generators SlteAddress if different than mailing address) <br /> ger Van a coo isirict West High Sct�oral <br /> ' 875:W Lowell Ave 1775 W Lowell Ave <br /> Tracy. CA Tracy,CA 95376 <br /> 209-321-3429 <br /> Generajaei Phone: <br /> 6 Transporter 1 Company Mama *** U.S.EPA ID Number <br /> ingenwm (Saca�menfo)( ERI PHONE-Gustli3#8766 0004�"�*) CAR000179747 <br /> 'T Tracts arter2 Company Name U.S.EPA ID Number <br /> 61'san Harbors Environmental Services MAD039322250 <br /> S.Destrtretead c!rborsn,4raegAonrite,LLG U,S,EPA ID Number <br /> 11600 North Aptus Road UTD981552177 <br /> Girants-Alle,UT84029 <br /> Facill€y's Phone: <br /> 435-884-8100 <br /> ga 9b.U.S.DOT Descr€piion(including Proper Shipping Name,Hazard Cfass,ID Number, 10,Containers 19.Tclal 12.Unit 13.Waste Codas <br /> HM and Packing Group(if any)) No, Type Quantity WL/Vol. <br /> 1 LIN1993,Waste Flammable liquids,n.o.s.(Isopropyl Alcohol, 559 D001 I <br /> o X Sodium Chloride),3, 11 ....� __ <br /> I <br /> w 2 UN3264,Waste Corrosive liquid,acidic;jnorganfc,n.o.s. 551 D002t <br /> X (Hydrochloric Acid,Magnesiurn Chloride),8,II <br /> 3,NA3082, Hazardous waste,liquid,n.o.s.(Stirrer,Copper),9,Ill 551 # DOI 1xi <br /> � <br /> 4, <br /> Non-RCRA Hazardous Waste Liquid(Ammonium Sulfate, 551 <br /> Magnesium Suffate) +� <br /> 14.Special Handling Inst uciions and Additional Information tom' <br /> Document D41464 Sales Order 60744 <br /> 1)Pr-o ile#15360 DOT ERG#128 WE•-1 J LCCRD 15G H2 3}Profile#15360 DOT ERG#171 WE-3/LCGRC/5G H2 <br /> 2)Prfofile#15.360 DOT ERG9154 WE-•21 LCCRAI H2 4)Pro€ile#15360 DOT ERG# WE-41 LCCRC I5 H2 is <br /> 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, <br /> marked and labeledlplacarded,and 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 /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknawledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if]am a small quantity gena lar)is true. <br /> Generators/Offerors Pdnt, yped Name Signature Month [lay Year <br /> `r 16•Intemational Shipments 6 <br /> Import to U.S. ElExportfrom U.S. Pogt antryle�y'P� <br /> Transporter signalure(for exports only): Dale leaving tJ .: <br /> re 17.TransporterAcknowledgmentofReceipt ofMaterials <br /> ul <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> Transporter 2 Printedfryped Name Signature Month Day Year <br /> e- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Refection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> ti • <br /> Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> ZIQ <br /> rHa.zTaWaste Report Management Method Codes(€.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2.Facility Owner or Operator:Certification of receipt of hazardous maledals covered by the manifest except as noted in Item 18a <br /> ame Signature Month Day Year <br /> 3A Farm 8700-22(Rev,3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IT'REQUIRED) <br />