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Form Approved.OMB No.2050.0039 <br /> Ploase punt or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1,Generator 10 Number 2.P o 1 f 3,Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAR000220046 909-984-99841011830320 FLE <br /> 5.Generator's Name and I-10ingAddress Generator's Site Address(it diffeierd than mai'#ng address) <br /> CALIFORNIA HEALTH CARE FACILITY (07557) 7707 SOUTH AUSTIN ROAD <br /> 7707 SOUTH AUSTIN ROAD (attn: H. Medlin) STOCKTON, CA 95215 (attn: Hetti.e Medlin) <br /> STOCKTON, CA, 95215 <br /> Generalot's Phono: 209 467-7904 <br /> 6.Transpener 1 Company Name U.S.EPA ID Number <br /> INDUSTRIAL, WASTE UTILISATION, INC. CM900585293 <br /> 7.Transporter 2 Company Name U.S.EPA ID Ilurnbei <br /> 8.0esignaleFadlilyNamaandSdeAddreas U.S.EPAIDNumber <br /> Reidioladora xemarry De Mexico SA de CV <br /> Carretera Federal NO. 2 MEX-TIJ, M4 121 <br /> Teeate,BCiMexico 21530 <br /> Facility s Phone: 665-655-1462 MXC130619001 <br /> go 9b,U.S.DOT Description linciuding Proper Shipping Name,Hazard Crass,ID Number, t0.Containers 11.Total 12.Unit 13.Waste Codes <br /> Hlt and Packing Group(it any)) No. Type Ouantily WI Not. <br /> i.-UN3175, Wae e Solids eon a g e , D001 F003 352 <br /> o X n.o.o.(alc=l/acetone) , 4.1, PQII <br /> 2, UNIWOU, WaOtO AOStOnSir D001 jF003 214 <br /> � 1 _ <br /> X ( '115 <br /> S OIn�3S/ IWC cl_ <br /> Hilt' H Tb'1.N WNO IA <br /> 4. <br /> 10Z 9 0 030 <br /> rK -aI Handh 9 tnsbuclwns and Addd vnal Information <br /> i) rage) R18-9201; ERG #: 133 2) acetone-app#R17 7 <br /> AV NG P12 'llvc� 10.4MIX <br /> R IL y 12C"tYYGI�✓ <br /> S, <br /> 5 uSar�rA/D riC40000/C�94i7 <br /> i . GENERATOR'SIOFFEROR'S CERTIFICATION:1 hereby declare that the contents of this consgnmenl are fully and accurately dascobed abave by the proper shipping name,and are classified,packaged, <br /> marked and labe!ed:placarded,and are In all respects in proper Gond tion for transport according to oppticallo international and national governmental regulations It 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 AclifnMedgment of Consent. <br /> 1 ce"Illyfilat the waste minimization statement identified in 40 CFR 262 27(a)(it I am a large quantity generator)o(j))(it I am a small quantify generator)is true. <br /> General s' fterof Pnnted+Ty Name R on ay ear <br /> ��/V/wjo- <br /> r,.J I6 to er ational tiprnents tp1import io U.S / ,1 ) IdlExpd bonU S. Poi of enlry.exY❑ <br /> Transporter signature(for exports only): ' Date leaving U.S.: <br /> �C 17.TransporterAcknaMedgmentof Receipt of Materials <br /> Transporter 1 PrinletiRyped Nama sign onIF ay car <br /> o C �' <br /> CL <br /> jx Transporter 2 Printed yped Nome ig al n Day ear <br /> 8.Discrepancy <br /> E 18n Discrepancy Indira6on Space Quantily ❑Type L1 Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Nlemate Facitily(or Generator) U.S,EPA ID Number ! <br /> _J <br /> U i <br /> Facility's Photo; <br /> 18c Sgnalure olAliemate Facility(or Generator) Month Day Year <br /> 4 <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,.disposal,and recycling systems) <br /> Uj ' 5 C� 2, H 0 2 o 3. a. <br /> 11F <br /> 04ner or Operator.Certification ofreceiptofhazardousmatedats covered by the manifestexcept as noted in Item 18a <br /> R ed Name Signalure Month Oa Year <br /> yp .—�--f nd o moican I 7L-If foe4 r3clo G) o <br /> EPA Form 0700.22(Rev.3.05) Previous editions are obsolete. DESIGNATEO FACILITY TO OLSTINAI•[ON STA'fF(IF Ct[OUIRCf <br /> I <br />