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Please print or type. <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number 12. Pad <br />CAD981456023 <br />Address ATTN: Mike Ublck <br />university tit The Pacific <br />3601 Pacific Ave <br />Stockton, CA 95211 <br />Generator's Phone: 209-946-29C <br />6. Transporter 1 Company Name <br />Ingenium (Sacramento <br />7. Transporter 2 Company Name <br />5j Form <br />of 3. Emergency Response Phone 4. Manifest Tracking Nu <br />2 800-633-8253 100024 <br />**ERI PHONE -Gust ID# 8766-0004** <br />Generators Site Address (il different than mailing address) <br />UniversityOfThe Pacific <br />3601 Pacific Ave <br />Stockton, CA 95211 <br />U.S. EPA ID Number <br />CAR000179747 <br />OMB No. 2050.0039 <br />2 5 DAT <br />Ingenium (Milpitasx****ERI PHONE -Gust ID# 8766-0002****) CAR000179747 <br />8, Designated Facility Name and Site Address U.S. EPA ID Number <br />Recidadora Temarry de Mexico, SA de CV MXC130619001 <br />Carr. Fed. No. 2, Mex-Tij, KM 121 <br />San Pablo Tecate, BC, Mexico, CP21530 <br />Facility's Phone: 619-270-9453 Chemtrec 2417 # EMERGENCY (800) 424-9300 <br />ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes <br />HM and Packing Group (if any)) No. TypeJ Quantity Wt.Nol. <br />1, <br />o UN1993, Waste Flammable liquids, n.o.s.. (ethanol, toluene), 3 , II D001 F003 005 <br />X DOT ERG#128 '� 57©� Q j �� 331 <br />w <br />2' NA3077, Hazardous waste, solid, n.o.s. (lead nitrate, methanol), 9 , D006 D007 D008 <br />X III DOT ERG#171 '9 2 iq <br />r ® 0 � , 0 F003 F005 352 <br />4. <br />11 1) 818-21060 2)R1&21062 Cyxc�9) <br />p� I41 Primary E>porter:TemarryRecycling,Inc.AOC Solvent 020514 E18001 Aqueous 020526 E18001 Solid 020530 E1800 <br />15. GENE RATO 'SIO FEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, aryl are classified; packaged, <br />marked and labelediplacarded, and are in all respects in proper condition for transport according to applicable intemationaland 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 EPAAcknowledgment 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) (ifi am a small quanti generator) is true. <br />Generator'slOfferor's PdntedlT d Name Si Month Day Year <br />rV,S (IM? 64L 1b <br />J 16. Int mational Shtpments <br />❑ Import to U.S. Export from U.S. Port of entry/exit: 2606 <br />Z Transporter signature (for exports only): Date leaving U.S.: <br />G= 17. TransporterAcknowedgment of Receipt of Materials <br />18. Discrepancy <br />r <br />18a. Discrepancy Indication Space ❑ Quanti ❑ T e <br />ty yp Residue ❑Partial Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />J <br />Facility's Phone: <br />w 18c. Signature of Alternate Facility (or Generator) <br />Q , <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. 2, 3. 4, <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted <br />2-17) Previous editions are obsolete. <br />in Item 18a <br />Month Day Year <br />Month Day Year <br />❑Full Rejection <br />DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br />