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Please print or type.(Form designed for use on el' ' , ewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Gensiato ID Number 2.Page 1 of 3.Emergency Response Phone 4, at c u �/ <br /> WASTE MANIFEST CAI20000155M 800-424-8300-CI4EM'fFt y � 6 31 JJ1i1 <br /> 5.Cenerator's Name and Mailing Address Generator's Site Address(if ditfarerd than mailing gess) <br /> Mountain Vary Expresm Co. <br /> PO BOX 2569 <br /> Manteca,CA 95336 tint Bas:airier Cir. <br /> Generator's Phone: 209-823-2168 <br /> Manteca.CA 95336 <br /> 6.Transporter 1 Company Name U.S.EPA ID Numb <br /> Fremot.tw Environmental Services tris. CAR000171017 <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> C!e:an Harbors Environmental SenAces Inc MAD039322250 <br /> 8.Designated Fatty Nara and SU Address Clean Marboris U.S.EPA ID Number CA0059494310 <br /> 1021 EWryessat road <br /> Sat&Jose,CA 95133 <br /> Facility's fie: 408-441-09152 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Contalnera 11.Total 12.Unit 13.Waste Codes <br /> HM and Pacldng Group(f any)) No. Type Quantity WLNol. <br /> i. UN2924,Waste Flammable Liquids,C041rosive,N.O.S.,(Tetrapropyi � DF � G 331 DOD D00 <br /> p Ordiooilicate),3,(8),illi <br /> Z 2R UP112d3.Waste Faint Related Material,3,II 00 LJ 4 Dki G 331 D301 <br /> UJ <br /> G�S <br /> to J. <br /> 3. i <br /> 4. I f <br /> 14.Special HandlingInstructions and Additional Information <br /> I 1-landlers TO B4f 40 I-W Trained And Use Proper PPE <br /> 981)CFF594364(Tetra(xophly Orthosilicate)ERO#132 3t�� <br /> 9821 C11-461043(WPRNHCommodity)ERCP#126 SS <br /> 15. GENERATORWOFFEROWS 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 Mdedlplacarded,and are in all respects in proper condition br transport according to applicable International and national govemmental regulations.If export shipment and I am the Primary <br /> Exporter,I oert fy that the contents of this consignment conform to the terms of the attached EPAAcVoMedgment of Cogent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large qua thy generato HI am a small quantity generator)is true. <br /> GeneraW rocs PrintedlTyped Nara Signa , Month Day Year <br /> l 7hrtEvl� t5��1� .c !�.; !C `3 !2. <br /> ri 16.international Shipments ❑Import to U.S. ❑Export from U.S. Port of entry <br /> IF Transporter signature(for exports only)_ Date leaving U.S.: <br /> W 17.Transporter AdamwledgmentofReceipt ofMaterials <br /> Trarnsporter 1 P n W/r arae Signorine Montle Day Year <br /> Transporter 2 Printed/Typed Name Signature - Month Day Y <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity [--]Type ❑Renk ❑Partial Rejecter Q Ful Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Numb <br /> V <br /> LL. Facil!Vs Phone. <br /> 0 180.Signat reAlternate Facility o Generator) Month Day Year <br /> d <br /> Z <br /> Lo 19.Hazes Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling system) <br /> r1 1. i s J, l 2. 3. 14, <br /> 20.Designated Facility Owner or Operator Cerflim inn of recut of hazardous materials covered by the manifest except as In karn 18a <br /> P N r 9natue moi} HbJNh Day Year <br /> r s 1' _E'( ' Y - y�-- ..e 'i-'K�✓ •-' /` �c <br /> E9Forrn8700-22(Rev.M5) Previous IMona1eObsolete. DESIGNATE OACfLITYTO GENERATOR <br />