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018821163JJ K <br /> fPlease print or type.(Forms designed for use on elite(12-pitch}typewriter. Form prcved.OMB No.2050fi039 <br /> UNIFDI2NtItAZARQ)us 1.GenershorlDNumber 2,P065Ief 3.FrRS9rB9�Mao no 4M�rilfe T E rflrer�63 JJK <br /> WASTEMANIFESTREM <br /> CSR 00� � 470 11C�QC��t��l6B / u [1 <br /> 5���ty��r ► �a 11 Gen�l��s'������.�� e �] <br /> 1120 1�-WATERLOO RD 114 <br /> STOCKTON, CA 95205 STOCKTON,CA 95205 <br /> Generator%P}2110'. " 7�1 <br /> 6,Tfansparter 1 Compaly Name U.6.EPA1D Number <br /> 041DWSEWCES WK 435 642 742 <br /> 7 a 2 Cam n Name U.B.EPA iD Nummi- <br /> 'JM ,fMOD M5 1 19 <br /> B.+D�esiggnatodF�a�dMyNamr�eyand SitaAdpdress $ COLOGY IDAHO,ING. U.B.EPA IDNumber 100 73 <br /> 114 MA <br /> VS- <br /> RD <br /> VII�k�p�yW 83W-4Facility's Phone: .'gym],274'1516 - <br /> ga, 9b.U.S.DOT Description{including Propel Shipping Narna,Hazard Class,ID Numbs, 19.Gontainars 11,Total 12.Unit 13.Waste Codes <br /> HM and Pack ng G oup(if any)} Na Type pueni ty Wtivol, <br /> T-sp <br /> ERG <br /> 001 VF OW49 P WN GM DM <br /> O A120 <br /> r xlf- 1 I Dols <br /> fW4 UMS N E3RG#123 EMS 331 <br /> 3 1 r 91 272 <br /> X91 f <br /> A. <br /> IHIFv�s��.3A:.Q.Y:a tl.iiY�liSq[JI,����Jlr:�a.t141.f�'�4.7� <br /> 15. GEN ERATOR'SlOFFEROKS CERTIFICATION:I hereby declare that the contents at this consignment are fully and aacuralely described above by Me prbpetshipping name,and are classified,packaged, <br /> mmkW and labeledlplacarded,and are trial respects In proper oWilion for irauspoitaceording to applieable infemaJional and pattonal governmental ragutalions.If axpol stvpmetriarrd lam the Piimary <br /> Exporter,J certify that the contents of this ecnslgnmgntcaniorm to the terms of the attached EPAWarawtedgment of Consent <br /> I certifythat the wasle minimization sta(ementidentitied in 49 CFR 262 27(a)(If I am a largequantlty generator)or(h)(if t am a smattquanlitygenefadx}ls4ue, <br /> GaneatorsfQgerntePrf ledfT ams 5lgnadlrelilt <br /> afe�ar <br /> "�4e1 <br /> Ifs.lInglifnational ❑lmpodtoU.S. ❑FxpertfvnU.S. Porlofentryl iE <br /> F— <br /> Tmnsparier signatara(for exparrsanly]: DaleJeaving <br /> w 17.TranspaterhrknoledgmemofReceiptofMaterlals <br /> j� Transparterl PnntedfFyped Name Signature K Mgtdb �r <br /> 0 M1 �i <br /> rpina I <br /> Transpuder2PrIntedlTypedNerna Slgnatu Month flay Year <br /> e . uo.-..rteI91 19 <br /> 18.Discrepancy tI--�� <br /> 18a.Discrepancy Indication Space ❑GuanGly f IType ❑Residua El Pdr(ial RejecSaal ❑Fah 13ef assort <br /> Man fast Relererrce Number. <br /> lab.Altamate Fadllty(or Generator) U.S.EPA ID N umber <br /> J <br /> C? <br /> u.. Feolity'sPhone:- Month Day Year <br /> 18c,Slgnalure efAltemate Faerlity(Dr Generator) <br /> 19_Hazardous Waste Reporl Management Method Codes{i.s.,cedes for hazardous waste Ireahnent,disposal,and resyGiag 9ybt9ms] <br /> LU <br /> f., 3. gHim d. <br /> 20.Desi dFao7ityownereroperator,CCHfeato tplalh rdausrnatadalsaSVeradbyttmmanifestexoegtas dlniteml8 <br /> Pined Signature Da a <br /> EVA F 700-22(Rev.3-05Y Pfevious editions are obsolete. D GNATED FACILITY TO DESTIN N STATE(IFR G1L31REC1) <br />