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, <br /> Please print or type.{Form designed for use: elite(12-p tch:typer,-.:.:- <br /> 1.Generator ID Number Form Approved.Oh19 No.2650-00. <br /> UNIFORM HAZARDOUS 2 Pa;_ . Emergency Response Phone 4, <br /> Ag, :1 <br /> 4,Manifest Trackin Number <br /> WASTE MANIFEST CAL00038M ti 209.944-5714-2002 016 8 7 5 4 4 J J K _ <br /> 5 Gen ELK NRma and Mailing Address Ge-erator's Sita Address(If different than mapmg address) <br /> P.O. 60X 6069 1120 CHARTER WAY <br /> STOCKTON,CA 95206 STOCKTON,CA <br /> Genera&s Phone: 209-944.5714-2002 <br /> 6 Transporter 1 Company Name <br /> GeorgeW.Lowry,Inc. U,S EPAiDNumber <br /> CAROOD047019 <br /> 7.Transporter 2 Company Name ` U.S.EPA 10 Number CC <br /> Z Cert-o 3 <br /> e Des F �reu U.S.EPA IDNunlbar <br /> 2730 E.13th St. AZROCW15924 <br /> YUMA.AZ 8t33C5 <br /> Facilitys Phone SIM341'c" <br /> ga 9b U S.DOT Description(including proper Shipping Name Hazard Class JD Number <br /> 10 Cosn�rs <br /> ta <br /> HM end Packing Group(d any)) 11.Total 12.Unit <br /> No. Type Quantity WLNoi, 13.Waste Lodes <br /> X 1 ENONRCRA HAZARDOUS WASTE SOLID(oily absorbent &deb4s) P 3522. <br /> OM <br /> W <br /> a. <br /> a. <br /> 14.Special HIr <br /> ERGtfa 1�71�kis and Additlanal Intorrnation f <br /> USE GLOVES INVOICE# <br /> 15 GENEf2ATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of This consignment Uty and accurately dascrtbed above the marked and laheledlplawrded,and are In all Mspecls in proper condition for by proper shipping name,aro are classified,packaged <br /> F�orter,I certify that the contents of this consignment conform f4 the tarots of the s R=Xdindied A toap it blQ International and national governmental regulations.If export shipment and I am the Primary <br /> I certify that ste rnhmizatkn statement klentitied in 40 CFR 262.27 a d I am a la a uan edgmao t(b Consent <br /> Generator'sJDlf {}{ >Q q qty generator)or{b}(d I am a smae quantity generator)is bus. <br /> yped Nerve S <br /> Month Day Year <br /> 1 S6 Interna� � `' � /� <br /> Transporter a)gnature{for exports only❑import to U.S, ❑Export from <br /> 17 T U.S. ort of—an trylexib <br /> Date leaving U,S.: <br /> erAcrnowledgment o{Receipt of <br /> C Transporter 1 PdntedrTyped Name <br /> w Signa4rre ` InDay Y ar <br /> 7 7 sparter 2 PrintedlTyped Name <br /> CU,4���� Month Day Year <br /> 18.Disaepanoy a3 t 3 l <br /> 1Ba.Disaepan„y!ndlration space <br /> ❑ Quantity ❑Type ❑Residua ❑Partial Resect. ❑Full Reject cin <br /> 186 Alternate Fawy(or Generator) Manifest Reference Number. <br /> U.S.EFA iD Number <br /> U ' <br /> F.,Wtys Phone <br /> LU t6c 5igrsatureofAltemaaFadGty(orGenerator) <br /> ZMonth Day Year <br /> W Hazardo,s Waste Report Management Method Codes(ie,codes for hazardous waste treatment disposal.and <br /> 4 t 2 <br /> recycling systems) <br /> 3, 4. <br /> 20,Designated F301V Dane,-or Operator Certification of reaelpt of hazardous materials if <br /> covered by the manifest ex <br /> PrintedlTyped Name except as need In Item i8a <br /> 5ignathre Month Day Year <br /> EPA Fort 8700-22;RaV.3-05'- P-womus editions are obso ate. <br /> DESIGNATED FACILITY TO DESTINATION STATE (IF REGUIRE, <br />