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SIS SHIP# rte RECEIVED BY SJCEHD: <br /> Please print or type. X 913 738"145 " 7r 11/04/2019 Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 11.GereratorlDNumber , . 2.Page. of 3.F-mee Re2s�p�n�se P. o �� 4.Manifest Tracking Number <br /> WASTE MANIFEST 1307314154 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Ai l eti A Waggoner Construct i on <br /> to-1 Sa Acoria. Ave <br /> R:i PON CA 9-5366-0000 <br /> Generators Phone, 209-599-8788 <br /> 6.Trgsparter 1.Company.Name U.S.EPA ID Number <br /> .xt t, SYSTEMS INCTXROOO@83.20 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address S ETY^'Ksl...EEN OF iAt-I F ORN$G U.S.EPA ID Number <br /> C-,fI 1 SMITH AVE. <br /> NE.WARK n CA 94-560 <br /> 10-`795--440f <br /> C:F�I'��3808874•f S <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> and PackingGroup(if any)} 13.Waste Codes <br /> HM No. Type Quantity Wt.Nol. <br /> 1. NGN-•-RCRA HAZARDOUS Will UOl,TD T i` `� 1222 <br /> 0 (.01L, WATER, SLllDBE) <br /> W <br /> 2. <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1-131) EVIS 81 S,33 Ski:'1 Al-4074S, <br /> 24h! retai-fed by generator confEir 55 a lvr s-ncy auti <br /> Qn initivil transporter to add orstlt?stititt�, �df"� inr;;= y i,, r; rA�:�r � on `�enetla zsrl s ispf all.„ <br /> 15. GENERATOR'SIOFFEROR'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 nafonal governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform is the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a((if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratoesfOfferoes Printed/Typed Name Signature Month Day Year <br /> 16.International Shipments' <br /> F ❑lmporf to U.S. ❑Export from U.S. Port of entrylexit: <br /> 91 Transporter signature(for exports only): Date leaving U.S.; <br /> Ce 17,Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 PrintedlTyped Name Signature Month Day Year <br /> Cn <br /> a rlbs Ing 1 ti <br /> Tran"po er 2 ffintedlTyped Name Signature/ Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Typej <br /> ❑Residue ❑Partial Rejection F]Full Re ection <br /> Manlfest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility{or Generator} Month Day Year <br /> a <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> us <br /> II 1. 2. 3, 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPJ Forp 00-22 fty V.17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />