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7--155--1,11 <br />,ace nrinn Mtvn2 1F0rm dneinned fnr' c <br />..1:1.. !77 n:Rn1.1 hrnn,a,nlnr i <br />Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />WASTE MANIFEST - . -- , <br />Generator's Site Address (If different than mailing address) <br />5. Generators Name and Mailing Address <br />WESTERN FARTIS SVC' INC VESTERH FAR11 SVC INC <br />1903 IN BROADWAY Fu BOX 3187 1755 H BROADWAY ST <br />STOCKT011 CA 175215 PO Box 5188 <br />Generators Phone., 207-347"'260-) STOCKTON <br />Cir 95205 <br />6 Trans �f an yN`ame / }r INCSC . U.S.EPAiDNumber <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />& Designated Facility Name and Site Address SAFETY-+' LEEN SYSTEM INC 000760 U.S. EPA IDNumber <br />6000 88TH STREET <br />SAGRRtiE�#Tti CA 95828 <br />916--386-•4913 <br />CAOCO0084517 <br />Facie s Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 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 />W(.Noi. <br />X <br />VASTE PAINT RELATED C(ATERIAL.3D UN1263r <br />DC( <br />, <br />!r <br />F003 <br />0001 <br />00448 <br />Ps III <br />Z <br />0033 <br />0039 <br />.12 T <br />a. <br />2. <br />3. <br />4. <br />l <br />14. Special Handling Instructions and Additional Information SK TRCK#110 x48260 0038303916 0000361776 0911 24 <br />1)E'fi�i�1�8 <br />SK AUTHORIZED TO RETAIN LIC $ ED SUBSE <br />15. GENERATOR'StOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuracy 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 EPAAdwadedgment of Consent. <br />I certify that the waste minimization slatemard identifiedin.gQGFR 2_82.27(a) Of I am a,[ aNge quortity generator) or (b) (if I am a small quantity generator) is true. <br />GeneraloeslOiferoes Print" Typed Name SignatureMonth <br />Day Year <br />16. IntDonal hipm nts <br />❑ Import to U.S. ❑Export from U.S. Port of entrylexit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter ntedtTyped Name S' <br />Month bay Year <br />TrInsporter2 PrintaTyped Name Signature <br />Month Day Year <br />18. Discrepancy <br />18a, DWeparxy Irrotcatron Space ❑ ci entity ❑ Type ❑ Residue ❑ Partial Refection <br />❑ Full Rejection <br />Manifest Reference Number: <br />18b. Allemate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: <br />18c. Signature of Alternate Fac4Eiy (or Generator) <br />Month Day Year <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. M141 <br />2'.... _I 1 1 ]3. <br />4. <br />20. D�nated Fadkty Owner or Operator: Certification 94eceipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Nam Signature <br />Month Day Year <br />At..D11 D- <br />a� 6�T2(.ty. M5) Previous editions are obsolete. � y 4C.71671rYHI GV rA6,rir-r r ■ ry ca�rr�nnDvn .��ne r:. `er rZd:OR VrR1VVI <br />