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DT' S C _ 045a, 2 - 0813'S- <br /> Please print or type.(Form designed for use on elite(12-;ft)typewriter) Form Approved.OM 6 No_205x0039 <br /> UNIFORM HAZARDOUS 1 <br /> 1.Generator ID Number 2.Page 1 of 1 3.Emergency Response Phone4.Manifest Tracking Number <br /> WASTE MANIFCsST C A F o o a 3 4 7 7 9 1 1 (80� 4949300 018 4 4 6 0 7 3 JJ K <br /> 5,Generatars Name and Mailing Address Generator's Ste Address(if different than mailing address) <br /> f LIlhT MOYEK5 19W W.FR MONT <br /> 193D W.FREMONT 5TOCKTON CA 95203 <br /> ';TOCKTON CA <br /> Generators Phone: 2094bW111 NorCal SoCal <br /> 6.Transporter 1 Company Name -- - U.S.EPA 10 Number <br /> WMENNIROSERV bAR000271D295 ' <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facilky Name and Site Address U-S.EPA ID Number <br /> CHEPACAL WASIL MANAGEWDT <br /> WAIT OLf15KYLINE RD. <br /> I[El ILEMAN CITY -CA W49 <br /> Faalityrs Phone: �59)3�r9711 �` '�n Q!3 4 f 1 - <br /> 9a. 9b.U.S.DOT Descoptien(ncluding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 14.Total 12.Unit <br /> HM and Packing Group[d any)) No. Type Quantify WtJlfal. 13.Waste(odes <br /> 1, rn <br /> o - <br /> _ G <br /> W 2. NCJN RL;RA HA7ARDOUSWA57t,5OL1U(HETKOLEUMA5PHALT,OIL) 352 <br /> TP F <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions andAddWonal Information <br /> EftC*:9t's1. 171,982. 171-ERS WO61(2376-LC <br /> 91511 CAfi14333-UMED A5PHALT EMJLSION/OIL Mx <br /> 24 FIR EWEkGENIC CONTACT:CHEM I RK 1D#CC#VE32907 <br /> 15. GENERAT OWSIOFFEROWS 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 Iabeledlplacarded,and are in all respects in proper condition for transport acoording to applicable international and national governmental regulations.If export shipment and I am the Prtrnary <br /> Exporter,I certity that the contents of ibis oonsignmeni conform to the terms of the attached EPAAcknoAW ntof Consent. <br /> I certify that the waste minimization statement idenfiroed in 40 CFR 262.2T(a)(if 1 am a large quantity gene I )or(b)(if l am a smolt quantity generator}Is true. <br /> erawsoffemes An fryped Name Sig a Month Day Year <br /> P <br /> 16.Inlematianal Shipments <br /> p_ ❑Importto U.s. El Export i4s'. Part of enlryfexit- <br /> x Transporter signature{far exports only): Date leaving U.S.: <br /> W <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> a Transporler f I'rintedlryped Name Signature Month Day Year <br /> ti c o►Q G a a c 1S s a +� o�' 3t] �S` <br /> QTransporter 2 Printeciffyped Name &gnatune Month Day Year <br /> � - <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity Type ❑Rosi e ❑Partial jection ❑Full Rejection / <br /> V%1_U&'jS. S0V&6A,a� O's n^1 {eSDI W l l 5bf�a Wn't x►1. WWseet, . <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> J_ <br /> C.'► <br /> La- Facility's Phone: <br /> 18c.Sgnature ofAllemate Facilly(or Generator) Month Day Year <br /> Q <br /> x <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � 1• 2. <br /> 20.Designated facility Owner or Operator.Certifica§on of receipt of hazardous materials covered by the manifest except as nailed in Item 18a <br /> PrvrtedlTyped Na e 56gnature hAO� Day <br /> 10011 R. <br /> ]fed <br /> EPA Form 8700 (Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 12910.0879 <br />