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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CALOW379M 1 800-424-300 010970288 JJ K <br /> 5.GepefKsdV aodMailianAddreWsgPO�n0N YARD Generators Site Address(if different than mailing address) <br /> 2112 LOUISE AVE K 2112 E LOUISE AVE <br /> LATHROP,CA 93330 LATHROP,CA,95M <br /> Generator's Phone: 209-941-740D <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> ENVIRONMENTAL LOGISTICS,INC CAR000217513 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.DeMaWfnAft WMCES, INC. U.S.EPA ID Number <br /> 180 WEST MONTE AVENUE CAD982444481 <br /> RIALTO,CA 92318 USA <br /> Facility's Phone: 800-888-4377 <br /> 9a, 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. Type Quantity WI.Nol. <br /> 1. I (ASM <br /> ALT ALT GRINDINGS '-9-- DM P 181 <br /> o CONT W44EAVY METALS) S Z3oa <br /> w <br /> Z 2. <br /> O <br /> 3, <br /> 4- <br /> 14. andhpg lOstrLchQrLS�NTAddiA Sl tr,formati WM� VY METALS S X5C 130 11001 WEAR APPROPRIATE PPE WO 01389" <br /> EMERGENCY RESPONSE COCHEEMIREC 1-80D-424-9300 CCN888232 <br /> 15. GENERATOR'SIOFFEROR'S 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 labeled/placarded,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 EPAAcknowledgment of Consent <br /> I cerrtily that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> 7ratorsJOfferors Printed/Typed Name Signature Month Day Year <br /> -j 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LU 17.Transporter Acknowledgment of Receipt of Materials <br /> T porter 1 Pnnted/Typed Nam Signature <br /> � Month Day Year <br /> O <br /> a <br /> za <br /> TransporterQZ*tedjTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type 11 ResidueEl j j <br /> Portal Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Ntemate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> LL Facility's Phone: <br /> Q 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. (( 2. 3. 4. <br /> l� <br /> 1 <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest t as noted in Ite 8a <br /> Printed/Type me Signa Month Da Year <br /> i a <br /> EPA Form 8700-72(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br /> 11371.0068 <br />