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SSL SI K SHIP# 221625244 <br /> ao � 7 � � b � ks � s , <br /> Please print or type,.(Form designed for use on elite(12•pitch)typewriter:) Form Approved;OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number 2.Pa 1 of 3 E sap 4.Manifest TrackingrN�umb r /� <br /> WASTE MANIFEST OAL000346875 9g 1 �~ l ti C3 1005742664 <br /> O 5 Z 4 G 6 6 4 S nS <br /> 5.G�grai $Name aid M($ <br /> Add as Genera] s dress{'[di rent than mailing address) <br /> l?i` H 60 i1 GAtL. f1 SW 1�t1 tl£'iit >?d Ti <br /> 1,13501 West *anford Rd Atte Samue3; Mchenry 18501 Stanford Rd <br /> TRACY Kf CA 95377 Attn Safety' Sam <br /> neneralcessPchtonne:: 209-539-3934 TRACY CA 95377-'9700 <br /> 6.Tgp e`f't_0qtMe SYSTEhMS1 INC. U.S.EPA ID Number TYR000081 05 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address A --I( E N SYSTEMS, INC, U.S,EPAID Number <br /> 600Q: SETH STREET <br /> SACRAMENTO , CA 9Sf34?-8 <br /> 916--306-4918 CA0000084S1? <br /> Facility's Phone;, <br /> go, 9b.U.&DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers ti.Total 12.Unit 13.Waste Codes <br /> HM and Paddng Group(it anyp No. Type Quant ty WUY01. <br /> 1. N —R RA HAZARDOUS WASTE, LIQUID DM T1 44 <br /> a (AOUEOUS FARTS WASHER SOLUTION) }' (0 <br /> '"( <br /> z 2. <br /> 3: <br /> 4 , <br /> 14.Special Handling Instructions and Additional information :24 <br /> 24 HR EMERGENCY 01-800-468-1,760 (SK i TFI i ��1'j� i �;t <br /> AUTH AS "AGENT FOR" BY GEN TO R)rtAN LICENSED SUB CARRIERS 15 NECESSARY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:1 hereby dedare thafthe contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and laboiedlplocarded,and are in all respects in proper condMon for transport according to applicable intemationata'd national governmental regulations.If export shipment and Ian)the Primary <br /> Exporter,I certify,that oontents of this consignment conform to the terms of theattached EPAAdmowiedgment of Cons t. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(5)(i(I em a large quanpty generator)or(b)(if m a small qu ity generator)is true. <br /> Generator's/offe PrintedlTyped Name Signature Month Day Year <br /> ltl03 lit) I'7 <br /> 16.Internationa Stupm is <br /> F- ❑Import to ❑Export from U.S. Roti of antrylexit: <br /> Z Transporter s(ghature(for exports only): Date leaving U.S; <br /> a 17.TmnsporterAdu*WedgmentofReceiptormaterfals <br /> Transporter PrintedrTyped Name Signature Month Day Year <br /> e U_ <br /> ,r t 03 0 �] <br /> aTran rintlpdayped Name $I natd Month Day Year <br /> be <br /> /., <br /> 18,Discrepancy <br /> 18a;Discrepancy IndicationSpace Ouant t <br /> y ❑Type ❑Residue �+� ❑Partial Rejection Full Rejection <br /> i Manifest Referehoe Number. <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> u Facility's Phone: <br /> W 187c.Signature RAlternate Facility(or Generator)` - Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,'codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1• H141' 2. 3 4 <br /> 20.Designated Facility towner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 185;, <br /> PrintedlTyped Name Signature Month Day Year <br /> IX-57t l :. <br /> EPA grro�7j14- x(:X4� Previauseditionsareobsolate'. DESIGNATED FACILITY TO DESANAON STATE(IF REQUIRED) <br />