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Please print or type.(Form des! nad for use on elite 12-pitch)typewriter.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2,Page 1 of 3,Emergency Response Phone 4.Manifest Trackln Number <br /> WASTE MANIFEST CAL0003OW '� 209 -5714.20M 016 87 5 4 4 JJ <br /> .944 <br /> 5.Generators Name and Melling Address Generators Site Address(if different than mailing address) <br /> 19ELKORP Ag. 1120 CHARTER WAY <br /> P.O. 60X (3069 STOCKTOI CA <br /> STOCKTON,CA 95206 <br /> Generators Phone: 209.944'5714'2002 U.S,EPA ID Number <br /> 6,Transporter 1 Company Name CAR000047019 <br /> George W. Lowry,Inc. <br /> 7,Transporter 2 Company Neme U.S.EPA ID Number <br /> ,�,� c! , ac 3�1 a L 2 <br /> 8.Desj F6 y % Wress U.S.EPA IDNumber <br /> 15924 <br /> 2730 E.13th St. <br /> YUMA,AZ t3Er965 <br /> FacilitI's Phone: 926'344-9828 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity Wt.Noi. <br /> X 1 NON RCRA HAZARDOUS WASTE SOLID(ojiy absorbent,&debris) DM P 352 <br /> Z 2, <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> ERG#P 171 <br /> INVOICE#t <br /> USE GLOVES <br /> e All <br /> 15. GENERATOR'SIQFFEROR'S 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 labeledlplacardedi and ore In all respects In proper oondlllon for transport according to applicable Intemafional and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the oontanis of this consignment conform to the terms of the attached EPAAcknowjedg(nent of Consent. <br /> I certify that th este miniml,:ation statement Identified In 40 CFR 202.27(a)(if I am a large quan(Ity generator)or(b),(!f I am a small quantity generator)is true, <br /> Generators/Off ated/TypedName Signet Month Day ear <br /> Alo <br /> -.a' 16.intematioria. . omenta <br /> � ❑Import to U.S. ❑Export from U,S. ort ofentry/exi <br /> Transporter signature(for exports only): Date leaving U,S,: <br /> W 17.TransporterAcknowiedgment of Receipt of M . 'als <br /> Transporter 1 Pdntedrryped Name M�th Day Y ar <br /> b <br /> Z <br /> Transporter 2 Printed/Typed Name SI r I Month Day Year <br /> 18.Discrepancy . <br /> 18a,Discrepancy Indication Space 0 Quantity 0 Type 0 Residue ❑Partial Rejection 0 Full Rejection <br /> Manifest Reference Number: <br /> 18b.Ailemate Facility(or Generator) U.S.EPA ID Number <br /> U ' <br /> uQ- Facility's Phone: <br /> w 180.Signature of Aitemate Facillty(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes,(Is.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> WO t, <br /> FPn <br /> Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Item 189 <br /> e ype me <br /> Signature Month Day Year <br /> EPA Form 870022(Rev.305) Previous editions are obsolete. DESIGNATED FACILITYTO DESTINATION STATE (IF REGUIRcLr <br />