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.1-A, 63HAW 22.145,1698 <br /> Please pri t-_ type.(Form designed foruse,onkllto(12?pitch)typewriter') <br /> IF0919 HAZARDOUS 1.GenerAbr ID Number,, 1 2.Page 1 of 3 m §''se PY9, <br /> �g 4.Manliest Tracking Number SKS W STE MANIFEST ,A4i7 "" `"� �f .632 <br /> V IlS <br /> 6,Gensraloes Name and Mailing Address Generators SiteAddress(If different than mallin address) <br /> ADMA - E-41den Sats AIDE # -w Bidden 622 <br /> West Stanford Rd Attn Samuel Mchenry 18501. Stanford Rd <br /> TRACY ' <br /> ' CA "377 Attn Safety Sae <br /> Generator's Ph 209-833x,313 TRACY i 915a77-9708. <br /> 6.Trgn.rj4Co n " U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility dame and Site Ad ressU.S.EPA ID Number <br /> q F tY li. t t �� <br /> ?C�8ft SMITH ME,, <br /> NEWARK .. t:{ �. .. . <br /> Facility's Phone: <br /> g %U.S.DOT Description(includingProperShipping Name,Hazard Class,IDNumber, 10.Containers 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity Wt.Nol. <br /> 1 NON- RCRA HAZARDOUS WASTE-, 1.1CIU IF TT <br /> 0 (USED GIL)gig <br /> 2. <br /> 3.: <br /> 4. <br /> d <br /> 14.Special Handling Instructions and Additional Information . <br /> T�'Ia.I a <br /> P,4 HR M RMiNCY1 r 800.46 --17P' (SK d TFI) v <br /> 15.`'GENERATOR'SIOFFEROR'S CRRTIFICATION: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 labeledrplacarded,and are in all respects In proper condition for transport according to applicable international and 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 EPAAaknowledgment of Consent. <br /> 1 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 quantity,generator)is true. <br /> eneretoerJ(Dfferoes Printedrryped Name Signature O q- Month t. Day Year <br /> i - Y <br /> —r: 16,international Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port ofentry/exii: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> V.TransporterAcknowledgment of Receipt ofMaterials <br /> e. <br /> �n,porter 1 Pdnte ype a e fl to Month Day Year <br /> 0 V, <br /> porter Pdn ype Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑(quantity ❑Type ❑Residue PP7I ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Atiemate Facility(or Generator) U.S.EPA ID Number <br /> J � a <br /> V s. <br /> U <br /> onth Day Year <br /> Facilltys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) M <br /> I <br /> 2 19.Hazardous Waste Report Management Method Codes(i.a.,codes for hazardous waste treatment,disposal;and recycling systems)' <br /> G 1. 2: 3. 4. <br /> 20.Designated Facility Owner Certification of receipt of hazardous materials covered by the manifest except as note/n Item 18a <br /> PrinteoMped Name Signature Month Day Year <br /> 4 <br /> EPA$Fgognn 8 p 22j(}Revue,{3O♦S Prey ons ate ob 1 DESIGNATED FACILITY TO GENERATOR .' <br /> i <br />