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RECEIVED BY SJCEHD`(EF) ON 10/8/19 <br /> PI ease pant i I <br /> or type. Form Approved.OMB No.2050-0o3 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Eme en Response Phone 4.Manifest Track! Number <br /> WASTE MANIFEST CAL0000i 8659 1 80F5�72669 0,12�6 314 7 F <br /> 5.Generator's Name and Mailing Address Generator's Site Address(f different than maili address) <br /> Kart #3174 Kmart#3114 <br /> 2099488205 21180€ Mariposa: Rd 2180 E Mariposa Rd <br /> Generator's Phone: St o kt ons CA 95205 Stockton, CA 95205 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Steriel+cleLLSpe ; asje Solutions Inc MNS006110924 <br /> 7.T rteimpany arae U.S,EPA ID Number <br /> e�c , n U.S,. <br /> � 2�2333 <br /> 8.Desi nated Facility Name a*ft- d411 U.S.EPA ID Number <br /> 4 I-St Avenue <br /> 109 ewood, CA 90301 <br /> Facilitys_phone..,. .�ti _. CAD808364432 <br /> 9a. 9b U.S. " Br 9hippi14 Narrle;Hazard Class,16 Number.' 10.containers <br /> 11.Total 12.unit <br /> HM and Pack+fig; ilpfahf) No. Type Quantity Wt,Nol; 13.Waste Codes <br /> i , , ' 'e1vironliwon a y azar ous <br /> a suh a4c�'", solid, n.o. s. (Mercury), 9, RG <br /> 2: on KGRA hazardous waste, so i ton <br /> ' Ballast), <br /> 3. <br /> 14.Special Handling Instructions and Additional 1nfomia6erY erCUrX On a z n i n g ast e) 2. 103408(Lamp Bail! as s <br /> 15. GENERATOR'SrOFFEROR'S CERTIFICA U:I hereby declare that dre Cdnifents of this constgrrtifent are fully and accuratety described above by the proper shipping name;and are r aesifred,;dtaged, <br /> marked and labeled/placarded,and are in all respects in proper Condition for transport according to applicable intematiofialand national governments[regulations.If export shipment and I am it*Prilna" <br /> Exporter,I certify.that the contents of this consignment cordorm'to the terms of the attached EPA Aeknowletlgmerrt of Consent <br /> ry <br /> I certify that the waste minimization statement identified in 40 CPR 262'27(aJ('uf i am a large quantity generator)or(b)(if I am a smalf qu City generator)is trice. <br /> _ _ <br /> Gene rslOfferors P med/Typed Name MOM` Day' Ye t <br /> _j 16.International Shipments AA . <br /> t- ❑Import to U.S. _,8*00 frorn U.S. Port of entry/exit: <br /> Z <br /> _ Transporter signature(for exports only): Date leaving U.S:: <br /> _. <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name <br /> Sgriature Month Day Ye�Y <br /> a- <br /> z <br /> P 03 12 201 <br /> risto her Almanza .. <br /> a Tra orter 2 Pn tedfr Name - _ _ <br /> a r. Signa Mordh' Day Year <br /> L4 <br /> 18.Discrepancy , <br /> 18a.Discrepancy Indication Space ❑ Qttan _, <br /> �Y 0 Type ❑Residue ❑Partial Rejection Full Rejection <br /> _.Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S,EPA ID Number <br /> J <br /> V <br /> u< Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> cy. <br /> 19.Hazaido ste Report Management Method Codes(Le., for azardous waste treatment drsposa I and re cling systems) <br /> 2 <br /> 3. 4. <br /> .. r <br /> 26. a TNilfty Owner or <br /> r.Certrfica f receipt of hazardous materials Covered by ail <br /> s <br /> �P ifest noted in(to 1 <br /> • PfinY'/Type a <br /> Y .. <br /> 8rM 700-22(fzev,t �y) Pry obsolete <br /> EPA <br /> sb4A' 1FDESIGNATED FACILITY-TR EST'SXSTEIVi <br />