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Please printor type.- Form Approved ONIB No UNIFORM HAZARDOUS 1.Generator IJ Number 2.Pape 1 of 3.Emergency Response Phone I4.Manliest Tracking Number WASTE MANIFESTW DOW Unr 13 r; �; �-} 4 FLE 5.Generator's Name and Mailing Address Generator's Site Address(if difleren!than mailing address) Goldon State Lumber 3033 S' Asrp9"Wer Sl oddon,CA 957W Generator's or Phone: 2�- -770 6.Transporter 1 Company Name US EPA ID Number EnvltewrwI N Solutions CAL OUG010 i Transporter 2 Company Name U.S.EPA ID Number EQ hdUStrfal SiftyiN MIK 41§ 642 742 8 Designated Facility Name and Site Address "' ' " U.S.EPA ID Number 1"ts Em!ogy H4hwayK 11 roles Soto of dotty NV6W3 Facility's Phone: 773-M3-2203 go 9b U.S.DOT Description(induding Proper Sh pping Name,Hazard Class,ID Number. 10.Containers 11.Total 12.Unit 13 lh'aste Coder HM and Packing Group(if any)) No. Type Quantity WtNol. Won-RCRAHaza�usft1dG.Sslld (Dobds) 1 v Z 2. LU - - - 3. j 1 i s i i 1piarr>Strucbons and Ad�igpa1lnfgm��o+ �� ��Me 0 ®'1®128390-25181 ZOZO GENCY CONTACT JEFF RHODES 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 dassif cd,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national gmremnwntat regulations-If export shipment and tre D.,a^, Experter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknawledgment of Consent. I certify that the waste minimizabon statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ill am a s uantity generator)is GeneratoeslOfferoes PrintedlTyped Name Signature — t"6r' Cay\ )�a.l J 16,Inlernalional Shipments Import to U.S. by � ❑ ExportframU.S. Port of en !exit: ? Transporter signature(for exports only): Date leaving U.S.: X 17.Transporter Acknowledgment of Receipt of Materials � Transporter t PrinledlPyped Name Signature a Z Transporter 2 Printed!T Name Signature Dar n_a' Q < 18.Discrepancy !/ 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Portal Rejection Rc,ea,. Marifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J \ U LL. Facility's Phone: w 18C-Signature of Alternate Facility(or Generator) Malt, pay Q Z N19 Hazardous waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C3 t ��Z 2 3. 4. 20,Designated Facility Owner or Operator.Certifica5on of receipt of hazardous materials covered by the manifest except as noted in Item 18a J Pn edlTyged"(,m(\ r Signa te' MoNh Day -Ya, I E?AFo 87, D ) Previous editibrisareobsolet . / DESIGNATED FACILITY TO GENERATOR