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Form Approved. OMB No.2050-0039. <br />3. Emergency Response Phone 4. M nit st T acl�'ng u be� _ <br />I I I I , 0 , 0. <br />1. Ger ID Number <br />UNIFORM HAZARDOUS 2. Page 9 of <br />WASTE MANIFEST �~�° ~I'501736 <br />$? <br />5. Generator's Name and Mailing Address 1' Generator's Site Address (if different than mailing address) <br />CAL T€ A14 DIVISION 10 CAL TRANS DIST 10 <br />1603 S ST 1603 T <br />TO T N 95206 I. DIV I N <br />Gener�astpopt s Phoned: a:r'""" s� TT <br />A 75205 <br />INC. U.S. EPA ID Number <br />TXR0000 50730 <br />7 Transporter 2 ,Company Name Y U.S. EPA ID Number, <br />8. Designated Facility Name and Site Address SAFE i Y L E SYSTEMS, INC.000 - U.S. EPA ID Number <br />88TH H STREET <br />S : . NT€# A 75828 <br />716-381-4913 <br />Facility's Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12.' Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt./Vol. <br />13. Waste Codes <br />No. <br />Type <br />1 AZ R WASTE, LIQUIDS , O.S. <br />x.34 <br />0 <br />9 A0 P III (D3) <br />Ire <br />Z <br />LU Z <br />z1 HAZARDOUS WASTE, I <br />MIMJJERSION <br />f34 <br />p �gLI <br />3 - CP U TE, LI I <br />1 34 <br />('AQUEOUS PARTS: DASHER SOLUTION) <br />4. <br />r <br />_ <br />14. Special Handling Instructions and Additional Information Ski € a° , 6498 00003701"T2 0"9 24 <br />1),E 171: <br />Sk, THBRI�. ' T RETAIN LICENSED SUBSEQUENT CARRIERS <br />15. GENERATOR'S70FFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described `above by the proper ghi ,ping name; and are classified acka ed <br />., <br />marked and`labeled/placardetl, and are in all re'spects,in proper condition for transport according to applicable intemationaland national governmental regulahons:.lf export shipment antl I am the`Prima; ry <br />Exporter, 1 certify that the contents of this consignment conform to the terms of he attached ElbAAcknowledgment ofConsent. <br />I certify that the waste minimization statement identified in 40 OFR'262.27(a).(if I am a large quantity generator) or (b) (if I amsmall quantity generate is t !u <br />s <br />_a <br />Generatots70fferors Print d yped Name Signature <br />9 <br />Mont Da Year) <br />" <br />J <br />F <br />16. International Shipments a� 6 <br />❑ Import to U.S. ❑Export from U.S. Port of entry et <br />Transporter signature (for exports only): Date IeaviK1.S.: <br />LL <br />17. Trans ort Acknowledgment of Receipt of Materials <br />oTransporter <br />a <br />1, Pr'ntedfFyped Name Sig ature <br />i ff e <br />Month Da Year <br />Z <br />Transportef2 Printed/Typed Name Signature <br />Month Day Year <br />t— <br />- <br />18. Discrepancy --L'. <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type <br />YP ❑Residue ❑Partial Rejection <br />❑ Full Rejection <br />7 <br />E <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) �" <br />U.S. EPA ID Number <br />V <br />Facility's Phone: <br />w <br />Q. <br />18c Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />UJ <br />® <br />1 "H14 2' 3. " 4' <br />20 Designated Facility. Owner or Operator. Certification of receipt of hazardous materials covered'by the, manifest exceplas jilted in Item 18a ` <br />PpmtgdlTyp d Na eigna <br />„ <br />Month Da Y r <br />PAFOrtm <br />87(p (Rev 3-n51 Previnnc aciitinnc <br />arc nhc loto <br />I I I I , 0 , 0. <br />