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i 14 <br />loam —W „r h,.,a rc,..rr, a—:,. —4 fnr —a nn arida N')-nitrhl tvnpwritpr l <br />16 Form Approved. OMB No. 2050.4439 <br />UNIFORM HAZARDOUS 1 •Generator ID Number d _ _ <br />2. Pag 1 of <br />3u Em rge y ge� nsep tie„ <br />tilic 4i )Ct � <br />4. Manifest Tracking Numberr <br />0 SKS <br />WASTE MANIFEST <br />5. Generator's Name and Mailin Address Generator's Site Address (if different than mailing address) <br />WESTERN FARMS SVC, I Nr-' CROP MOM -'T I tlF: s�' DSV ICE � <br />1903 N -BROADWAY PO BOX b 1881753 N BRUAiY, 11Y I' <br />STOCKTON Obi x:'w:,tr r" PO BOX 5185 <br />Generators Phone: ST0C%1, ft.d(+t ;,P 95205 <br />e. W.9911Y 99 SYSTEM a, INC. U.S. EPA ID Number T XtR0000509:30 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Fadrdy Narms and Site Address SAFETY—K LEEN S S T MS t INC. Uj.-Ef.'AJD Number <br />6000 88TH STREET <br />SACRr'�MFNTU � CA958,18916--386-4913 <br />('4100010108 451 <br />Facility's Phone: <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13, Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Arol. <br />X <br />1 WASTE PAINT RELATED MATERIAL, 3, UN126.3, <br />Did <br />P <br />F003 <br />D001 <br />0018 <br />n: <br />i <br />Pa II, <br />, <br />D035 <br />D939 <br />212 <br />C <br />2. <br />9 <br />r <br />3. <br />4• <br />14. Special Handling Instructions and Additional Information 5K Spy I M03854686 53784871 369976 CSG <br />D ERG# 128 - <br />-- cIENTRACT 94138) <br />24 FIR EMEAsENcY #1-800-468-1760 (SA ETY—t(LEEN1 <br />I <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this com ignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labekdlplacarded, and are In all respells in proper condition for transport according to apokxble intemational and nates 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 EPAAcknowledgment of Consent. <br />Ma-% to • ' t.WenUW.inAO CFR 262.27(a) (d I am a loge quantity ) or (b) (if t am a small quantity generator) is true. <br />G erator'sl0fferor's Printed[fyped Nara Signature Month Day Year <br />l <br />r r <br />16.Intemagonal Shipments <br />❑ Import to U.S. ❑ Export from U.S. Pon of 19 !exit: <br />Transporter suture (for exports only): Date leaving U.S.: <br />17. TtansporWAcknowiedgment of Receipt of Materials <br />T„ 1 PriMedlMi Signature Month Day Year <br />` f <br />Tra er 2 PrWerl/Typed Name Signature Y Year <br />18. Discrepancy <br />18a. Discrepancy Indication SpaceQuaOtity E] Type El Residue ❑ Partial Rejection El Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA 10 Number <br />I• <br />Facirflys Phone: <br />18c. Signature of Alternate Fadlgy (or Generator) Month Day Year <br />19. Hazardous Waste Repot Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />3. <br />4. <br />20. Facaq owner or operator: Certification of receipt of hazardous materials covered by the manifest ex as noted in Item Ila <br />PrintedfT_ Signa Month ay Year <br />.G T---1� <br />A Fran A7ATM 19law 'A -ARI Pfatrimm orfilim< Arp nhCnfPtp SIGN &Ys ACILITY TO GENERATOR STA (IF REQUIRED', <br />3 �267li50t <br />