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+ pTS(. f i'1 r t 103 <br /> Please print or type.(Form designed for rise on elite(12-pitch) r,) 612602399003 SCPPW 10/6/2009 Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 11.Generator ID Number 2.Page t of 3.Emergency Response Phone 4 anlfest Treekin Number <br /> WASTEMANIFEST CA0981i83975 i (Bo0>4 M718 00023039 MWI <br /> 5.Generators Name and Mailing Address Genereta's Site Address(if different than mailing address) <br /> n USD Tramp Yod <br /> 19$2 N.EI Pini Drive SAME <br /> Stockton,CA 95205 <br /> Generators Phare:(209)933-7045 <br /> 6.Transporter t Company Name U.S.EPA ID Number. <br /> Clean HaftmEnviron I ServicesIna MAD039322250• - <br /> 7.Transporter 2 Company Name U.S.EPA iD Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 022 195Rja@d"LW CAD0594943LO <br /> San 1oae,CA 95133 <br /> Faeuitys Phone: (408)441-0962 <br /> ga, 9b.U.S.DOT Description Wuding Proper Shipping Name,Hazard Class,ID Number, 10.Comm'ers it.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group('d any)) No. Type Quantity Wt Not. <br /> 1'N/A,NON DOT REGULATED MATERIAL,(EMPTY DRUMS Ar <br /> ® NONE- 008 DM 00290 P <br /> z 2. <br /> LU <br /> t9 <br /> .3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1.Ct1405124 4X55,4X30 <br /> 15. GENERATOR'SfOFFEROWS CERTIFICATION:1 hereby'dedare that the contents of this consignment are fully and accurately described above by the proms slapping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all reeds in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I car*that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste min imizaBon statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(d I am a small quantitygperavistrue. <br /> Generata's101feroes Printed/Typed Name Signature Month Day Year <br /> a / 11 lie 109 <br /> -116.International Shipments <br /> 1= ❑Import to U.S. ❑Export from U.S. Port of enbywit. <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter t of Receipt of Materials <br /> 12 Transporter 1 Pninted/Fyped Name Signature Month Day Year <br /> ra MARC SANnAGO III C 11 1s 09 <br /> Transporter 2ftte&7ypdd Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Numb <br /> V <br /> W Facility's Phare: <br /> w 18c.Signature of Aftemate Facifty(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatmrerd,disposal,and recycling systems) <br /> ® 1. H141 2. 4. <br /> 3. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the ma' as rded in item 18a <br /> t ypea Sig2WAF, <br /> Mon(h Da Year <br /> EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. DECILITY TO DESTI STATE(OF RE®UIR D) <br /> Cken Hat's tie ithe appropftite pwmita for arts l 0647.1667wasu ttm germaw is ti m <br />