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Please print or type. {Form designed for use on elite (12-nitchl tvoewriter ) <br />Corm A---4 nnao ei., Oncn nn')n <br />-wI FI UV!UV S cUMJI 10 a;c UU6u1ere. �"r°;J O �� .d-, ,!,i S'�:.4 {;'1 n,� ��_ t. 's ���;,. <br />UNIFORM HAZARDOUS <br />1. Generator ID Number 2. Page 1 of <br />3. Emergency Response Phone 4, <br />Manifest Tracking Number <br />WASTE MANIFEST <br />CAL000 33 7276 <br />5559-277-10US0188000266JJ <br />K <br />5. Genera -ices Name ane Mailin Address Generators Site Address (if different than mailing address) <br />Pacific Eihanoi Stockton LLC <br />3028 wavy Drive <br />Stockton, CA 95206 209-851-4073 <br />Generators Phone: <br />6, Transporter 1 Company Name U.S. EPA ID Number <br />All Willey Gisposai, Inc. C;AR 0018/686 <br />7. Transporter 2 Company Name U.S- PPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />US ECOLOGY VERNON INC. <br />5375 S. Boyle Avenue <br />Vernon, CA 90068 323-277-10€16 <br />Facility's Phone: <br />oa <br />9b. U.S. DDT Description (including Proper Shipping Name, Hazard Class, iD Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group ;ii any)} <br />Quantity <br />Wt./Vol. <br />3. Waste Codes <br />No. <br />Type <br />� <br />�y <br />Ay t}� pv�/{ Har - t u�ia refi.^! dr�iFxf rinhricl <br />'V 1 i1s'+t 52 zcA[ V1i VtS fY �Vi>>-i <br />® <br />t <br />i1+Al�` Mw. w�i <br />LL1 <br />2. <br />'L!f <br />1 <br />( <br />3 <br />� <br />4. <br />1 <br />14. Special Handling Instructions and Additional Information <br />9b.1) Oily debris profile# P211816 ERG 171 9b.33 <br />rdb.2) gi3.4) <br />15. GENERATOR'SJOFFERQR'S CERTIFICATION: I hereby declare that he contents of this consignment are fully and accurately described above by the proper shipping name, at are classified, packaged, <br />marked and labelediplacarded, 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 Ackneavredgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity gererator) or (b) (if I am a small quantity generator) is true. <br />Generato'slOfferor's PriniedlTyped Name ` paA Signature Month Day Year <br />-0 <br />F- <br />� <br />16. International' Shipments 0111 <br />I Import to U.S. ❑ Export from U.S. P <br />= <br />of enirylexit: <br />T ons o ar signature {for ex orfs onl <br />P 9 p y): Date leaving U.S.: <br />17. Transporter AckirgMedgment of Receipt of P;laterials <br />a� <br />Transporter 1 Printe Fryped Name Signature Month /Day Ye 7r <br />Transporter 2 Pnnte67yped Name Signature Month Day Year <br />F- <br />18. Discrepancy <br />18a. Discrepancy indication Space ❑ Quanti h' ❑ TY� ❑Residue :J Partial Rejectior. Ll Full Rejection <br />Manifest Reference Number_ <br />18b. Altera <br />Alternate Facili y (or Generator) U.S. EPA ID Number <br />U <br />Facility's Phone: <br />yLu <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />F - <br />Q <br />19- Hazardous Waste Report fUtanagemoni Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />ILI <br />1. 2. <br />3. <br />4. <br />20. Designated Facility Ogvmr or Operator: Certification of receipt of hazardous materials covered by the manifest except as nKed in Item 18a <br />Pr ritednfyped blame Signature Month pay Year <br />-wI FI UV!UV S cUMJI 10 a;c UU6u1ere. �"r°;J O �� .d-, ,!,i S'�:.4 {;'1 n,� ��_ t. 's ���;,. <br />