Laserfiche WebLink
Please print or type.(Form desi;;ned for use on elite(12 16th}"mftr,) Form Approved.DMB No.2050.GM9 <br /> UNIFORM HAZARDOUS 1 1.Generstor ID Number 0 12.Page 1 of -7TwXnv Number <br /> 3-Ey <br /> 60pMP <br /> WASTE MANIFESTIMAR001302"6 10 _9& 0 00144817 Mwi <br /> 5.Generstors Name end Mating Address Generator's Sb Address(If a%rw than mating address) <br /> Mv%Mtft4.n vasung Empress Co "Oftezew- 1019 Dwsmsez Dz. <br /> PC Bcw 2569 Smakwn, CA- 953361 <br /> Manteca, CA. 95334 <br /> Generetor's Mwe. 4011-GAI%14 1 <br /> 0.Transporter I Company U.S.EPA ID Number <br /> r7.Traniftlerl Camp"Name U.S.EPA ID Number <br /> ..Designabd Fecft Ne"and SNe Address U.S.EPA ID Number <br /> K-axs am GF T5Z=X <br /> FsA fe Ph—: S12IN-2-19-Afta Im Bologna <br /> gs. 9b.U.S.DOT Desorlplion Priduding Proper Shipping Nams,Hazard CAM,ID Number, 10.ConlsYtefa II.TGW 12 Ura I&woo cladel <br /> HM and Pad"Group(If Ifty)) Na Typo QMW WAlbL <br /> Ll RI101 M.0.S. 1r. 11 <br /> W <br /> 3- <br /> rM%twI <br /> -ca <br /> LOW <br /> Cl '?(A\\ V-Q (DOM) <br /> W <br /> 14SpdirV al lnbtion <br /> : <br /> 0. 1) <br /> W= 20 8= UT a nw— Svc. GCK3; <br /> 15. GENERATOWNWERMSCOMFICATION: I hereby dedars that the contents ofthisconsignment we fully and awistelydascrted above by the proper shipping name,and are claselled,packaged. <br /> marked and labeled0000rded,and are In all respects In proper condition for transport acowdrig to appileable Intemational and national governmental regulabons.H export shipment and I am the Fdffwry <br /> Exporter,I cwft that Me wrtents of this amalgriffoent conk to the terms of ft atWdW EPAAdmoWadwrant of consent <br /> I off*that the waft mirdmintlon statement Identified In 40 CFR 262.27(a)(If I am a large qUanKy generstor)or(b)(4 1 am a small quantity goveretDr)Is true <br /> GanaratorWOftror's PrinWyped Name sIgnature Wnth Day Yea, <br /> fZ-cl4 - I / I <br /> --X-16.Internewnal Shipments El Import to U.S. F-1 Export from U.S. Port of antrylexit <br /> Transporter slwwturs(for exports only): Date leaving U.S.. <br /> 17.Transporter Adm Wedigmarl of Receipt of Materials <br /> gov <br /> Transporter I Aln d/Ty*Nwre ftnature Y, <br /> R I <br /> Ca zof—"Y=!S� <br /> IL1 Y.-N5-.W'2 Name Signature MMM Yew <br /> 18.DIsC=Mpannv— IV <br /> 18a.DlKmpBncy Wkstion Spm Qu.ray []Type El Residue EJ Partial Rejection �Ful!Rejection <br /> C-Ah05(qlE:4-> ell-1 LAP-%t; D V- WV- -Me5.SA STV RS W' K,e-, I- I <br /> Manifest Reference Number. <br /> I Ob.Alternate Fadgly(or Generator) U.S.EPA ID Number <br /> 'It. Facilky's Phone: <br /> I k Signature olMemate Facility(Of M;Gtar) <br /> 19 HwArdous Waft Report Management Melhod Codes(i*..codes for hazardous waste trastmert deposal.aind recycing systems) <br /> 4, <br /> 20 <br /> Fadity�X or Operator..CetlfAn aft,of receipt of haitardous misladels wmed by the maniftJopipla noted In Item Igo. mom 1W 1w. <br /> I M- - '10, <br /> EPA Form 8700-22(Rim 3491 V%viofis etiftins ere nbwft DESIGNATED AGILITY TO DESTINATION STATE(IF REQUIRED} <br />