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BEL 10 <br /> Please print or type. Form Approved:OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number s 2.Page}of 3.Emerenc Resanse Pho e 4.Manifest Tracking Number <br /> w,�sTE MANIFEST006687167 <br /> , �, % : 1-00 - q,.• SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> , 601.3' IS 5-11; <br /> STOCKTON CA <br /> Generator's Phone: 209-948-7613 ®�® <br /> s.Tr?fiP6�� T.25I sw 7`rl 1 U.S,EPA ID Number 'X R0000_8r <br /> 7Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address AFETY~`1KLI'EN Off° GAi I F a .f U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWAAK <br /> Eacilily's Phono: <br /> ga 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, �® 10.Containers 11.Total 12.Unit <br /> H�L1 and Packing Group(if any)) 13.Waste Codes <br /> _ No. Type Quantify Wt,Nol. <br /> Z 2. <br /> iLE <br /> Lfi <br /> 3- <br /> 4. <br /> 14,Special Handling Instructions and Additional lnfarmation l SO�E VO 78-490935 CA47954 <br /> 2414 EMERGENCY%609j-468- 1 f60._.0 .'SK/TFI'-Con tract retained by geflp ator Confers a, ����:� <br /> 3R '!�I �. . 'i7 � '-_ ��"" �!^', ';c ..i ;fL€i s ('� a 5- n'i' °',' !'t R +4 _a�, I '_ <br /> 15. GENERATOR'SlOFFEROR'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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minim4afun statement identified in 40 CFR 262.27(a)(If I am a large quantity generator)or ib){if I am a small quantity generator)is true. <br /> Coeaerat©rs�Elffero s Printedfryped Name Signature 4lanlh Day Year <br /> 16.International Shipments <br /> ❑Impe€f to U.S. ❑Export from U.S. Port of entryfexil: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W V.Transpoder Acknowledgment of Receipt of Materials <br /> LIJ �.m..,... _ <br /> Transportet'Printed Typed'Jame ,Signature µ . ' Month Day Year <br /> fTampo ter 2 Printedf yp d N me Sj nature"' 141orilh Day Year <br /> R <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue Ll Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> >' 1&b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> C3 <br /> UC– Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> GC <br /> cep <br /> 18.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling system,) <br /> 1 2. 0. 4, <br /> 20-Designated Faciii(y Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlfypedName Signature Month Day Year <br /> EF'A Form 8700-22 jRev.12-17) Previous editions are obsolete. v <br /> 1)6651/156030 GENERATOR'S's INITIAL COPY <br />