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• <br />P[.. nrtnt rw tvoe_ (Form deskMW for use on elite (12 -pitta) typewriter.) <br />11111111M1111 <br />Farm Approved. OMB No. 2050.0039 <br />ECd 22 (Rev. ( itiws ald"43 43 4024-9459 PIAW51 ®ESIGNt#j j&rAgILlTY TO CK ]fiN ST8Tq (f REQ#lFf P) <br />tN IFOfiFA'HAZARDOUS 1. Generator 10 Number <br />2. Page 1 of <br />3A % Ph" <br />4. Manifest T11CMq Number <br />1 004510999 FLE <br />WASTE MANIFEST A 1. 0 0 0 3 5 7 4 9 7 <br />z <br />8M 932 4-0804 <br />5,s Name WMaH'ing Address CV, J�, #3wa GeneraWS SiteAddrM (if different than matt address <br />1885 West 11th Street <br />Tracy. CA 95378 <br />Generators Phone: <br />6. tanspm 1 cawany <br />U.S. EPA ID Number <br />S 0 0 0 1 1 0 9 2 4' <br />ericycle Spedalty VVbste ScilL ions Ino <br />MN <br />7. Transporter 2 Company Name U.S. EPA p Numbar <br />! Chemical Disposal Into AD 9 8 2 4 9 2 3 9 9 <br />8.Designated Facility Name and Site a Inc. U.S. EPA ID Number <br />2070 Executive Drive <br />ird is, IN 48241 N R 0 0 0 1 1 0 1 97 <br />Fade s Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Kazard Class. ID Number. <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and padd^9 Grow (day)) <br />Quantity <br />WtAV. <br />V. <br />'Non RGRA hanadws wasie. HWd <br />a <br />0 <br />"Sia. <br />,,� <br />Q 0 1 <br />CF <br />0032 <br />LU <br />?Jon RCRA hazardous wase, solid <br />3. <br />4. <br />u �( ep gUf05 -CA) 1887111 <br />50404-CVS(SM ReAtdMecl Solids - CA) <br />15. GENERATORwFFEROR'S CERTIFICATION: I hereby declare that the contents offt consigrimerd ae fully and aaaxatery described above by the proper stuping name, and are dassified. . <br />marked and labeledWcarded, and ane in at respects In pmpa = ditao for transport amordithg to applicable irnamational ad natlonial gmameft regulations, t exportslvipment and t am the Prfmhary <br />Exporter, I oac9fy that the oorttents of the consWeant cwftmh to the terms of the attached EPA AdMi0ledgirmt of Cahsad. <br />I certify that the waste minimizatim statement Identified in 40 CFR 282.27(a) (d I am a large quantity generator) or (b) (If I am a jet Quantity, generator) Is titre. <br />GeneratoeTs PfintedifyeAkame 1,16fith YM <br />J_i <br />4 f8 1 <br />1 S. herr Sdipmats ❑ to U.S. ❑ Expert tam U.S. Pat of ahtrytexlt <br />T efor Date U.S.: <br />IX <br />17. Transporter Admwledgmard of Receipt of Materials <br />Transporter 1 ea <br />eine <br />Jesse Romo 4 i <br />ararsporter <br />2 PrintadlT Name m Year <br />MOM= Q 2q 1 <br />18. t>isvepancy - <br />18a. Disceparcy Indication ❑ Quantity ❑ Type ❑ ❑Petal Rejediorh ❑ Fnll Rejedbn <br />Manifest Reference Number: <br />18b. Monate Facifity (err (3enerator) U.S. EPA ID Number <br />f.9 <br />wv <br />Fadfi s Phone: <br />LU <br />tete Fadtity (or Generator)) Month Day Yea <br />18e. Signature of ma <br />Q <br />Z <br />F) <br />19. Hazardous Waste Report Management Method Codas ¢.e., codes for hazardous waste beawent. disposal. and n riding systems) <br />® <br />1. <br />2. <br />20. Designated Facky Ovmer a Operator. Certification of rrloaO of hazardow covered by Me+manifest except as noted 18a tie <br />Pin Nairne Doth Wy / } Yea <br />Q�ww� /I+3 <br />ECd 22 (Rev. ( itiws ald"43 43 4024-9459 PIAW51 ®ESIGNt#j j&rAgILlTY TO CK ]fiN ST8Tq (f REQ#lFf P) <br />