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71 111111I111Ill I'III IIll 11111111HEIll IIII <br /> 002663945 $ KS <br /> Please print or type.(Form designed fo use on elite(12-pitch)typewriter.) Form Approved.OMB No.20504 <br /> 1.Ge rator ID Number 2.Pa 1 of 3 E c Re seph 4.Manifest Trackin Number <br /> UNIFORM HAZARDOUS I CAI.000 Ell Qtc 2 g4� i-"�,r�61 Y xf �—i�� 0 0 2 6 3 9 4 5 SKS <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> AUTOZONE -- CALIFORNIA AUTOZONE # 3. 15 <br /> PO Box 2198 ATTNTLDRYAN Bi.AIR 1122 W 11TH ST <br /> Generators Phone: c .3 _4911 TRACY CA 95376 <br /> 6.T9�spo -( o a N i?e s:, r„-_ r, U.S.EPA ID Number W �5 <br /> ,af-ir� � ��k�4 �f,�l Fi�las INC. T X h I,�t171tZttt,.14rJ930 <br /> 7.Transporter 2 Company Name i U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Add ressr . . D Number <br /> us ECOLOGY NEVADA dJ <br /> 1�_� . <br /> h 11 MILES 5 OF BEATTY HWY 913 <br /> £:FATTY f NV 0,31 F <br /> H0- 9-3'343 NVT3; 00 1 00141 1 <br /> C Facllftys Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> � 13.Waste Codes <br /> 1 Y HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1' MON RC'RA HAZA DOUS W TE,SOLID i DM _ �} ?'0- <br /> ca o (ABSIORBENT) I ZS <br /> z 2. <br /> - o <br /> -00, 3. { <br /> O 4' <br /> CD <br /> CO <br /> 14.SpecialHandling lnstructiand Addi nal Information SK SHIP ; �Qf1,,�7 CCG; <br /> 0 <br /> ' 24 HR EMERGENCY ft-800-469-1760 (SAFETY—KL.EEN — CONTRACT #94139) <br /> SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 0 0741140r.,OV380 <br /> C: 15. GENERATOR'S/OFFEROR'S CERTIF ICATION: 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 at(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 /> p- Exporter.I certify,that the contents of 9 is consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 1 certify that the waste minimlzadon sta ement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b);Jm a small quantity generator)is true. <br /> ( C Signature Month Day Ye: <br /> Genera r's/Offeror'.Printed/Typed Name 9 <br /> E —.r 16.International Shipments <br /> I— ❑I d to U.S. ❑Export from U.S. ort ofry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> fA 0. 17.TransporterAcknowledgment of Receipt 0 Materials <br /> C: <br /> Transporter 1 Printed/Typed Name Signature Month Day Yer <br /> aD o14— t! � 3 <br /> In r <br /> QTransporter 2Pdnte yped UAme Signature Month Day Ye. <br /> (q 18.Discrepancy <br /> O 18a.Discrepancy Indication S ce ❑ uantity ❑Type <br /> ❑Residue ❑Partial Refection ❑Full Refection <br /> Manifest Reference Number: <br /> Ja 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Atemate Facility(or General r) <br /> Month Day Ye <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Me od Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1' 2. 3. 4• <br /> 20.Designated Facility Owner or Operator:Cert fication of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba <br /> PrintedlTyped Name Signature Month Day Yea <br /> 4T vious <br /> ohs are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRE <br />