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5S!- K SHIP '.157 t` r7 <br /> X5 <br /> Please print or ype.(Fogn designed jhr iuSe'on elite(12 pitch ewnter)' <br /> UNIFORM HAZARDOUS 1:'Gener4tor ID Number Form Approved.OMB No,2050-00 9. <br /> CALOOVJ371C5@ 2'Piga 1 of 3. me R spo se ph qe 4 Mantles Tracking Nymbsr <br /> WASTE MANIFEST'. :r : j •L 1w{ Y.�Fbt�'-1.9tyQ1 j� /� �[ <br /> S:Goneralor'sName and fu�ng-Address 047 4 SKS <br /> A}.CR Iron .And Notall Generator's Sit aAddreasQfdd(erentthan mailing&caress) <br /> 1815 Navy Dr <br /> Stockton CA 95286-:1.17B: <br /> Geheralota Pho m: � -16773 <br /> B.Tra(ysporiellY� t� 8YVE S- YNCe U.S,EPAIDNumbe7 <br /> r .F.'fXRO�D�G�S 9�'>Zi5 <br /> 7.Transporter 2 Company Name + <br /> ' U.S.EPA ID Number <br /> i...�.ter.._ ... <br /> B.Daelgnsl@d Fsdfily Name and SlleAddreeb CL��� HARBORS BUTTONWII_10Wy LLC U.S.EPA ID NumbeP y" - <br /> 25N LOKERN. ROAD <br /> $UT i ONW 141-OW `�Si?($E, <br /> 6fi1�76i�-fi�0(b <br /> .i Facility's.Phone:'" - '•�: CFiU98�7675�:l6 i <br /> 9a gb.U.S.DOT Deeedptlon(Including Proper Shlppog Nama,Hazard Class,ID Number, <br /> HM and Paddng Group Qf any)) 10 Conlelrrera d1.Total 12 Unit . <br /> 1 `W1JNE NON RCRA. HAZARI10115 WA57E LIQUIDS Na. 7ypa Quantity . . . . 19 wa ct)de�'r <br /> .0 t {OCL -AND WATER), NIA ! Dhl. ' =A <br /> W z4. i <br /> 777 <br /> ' 14:Special Handling Instructions and Addl ode N <br /> TSD Ii Hl. 66507739 AL3 7.1_'. . ' <br /> <E4'HR`-AE GENCY #F1_000-468--1750 -(8A E`TY—KLEEN) <br /> 'SFC AUTHO IZ6Tx TO REtF17N LICENSED SUBSEQUENT.CARRIERS AS.IVECEESARY' <br /> 15.. GENERATOR'B/OFFEROR'9 CERTIFICATION:I hereby declare that the contents of this cdrrdgnmenl are fully and accurately deBcdlrgd above by the proper shlpplrig'name,Arid°are classified, adaa P <br /> marked and labeledlplecarded:and are In yit;raspecls In proper condition for transport according to applicable inlafnallonal and na8onal gbve!nmenlal regulations:If export shipment and I aro Pthery", <br /> Exporter,I certily that the contAnts of this consignment conform to the lermse'ilio alfeched EPAAcknowledgment of Consent p �_ <br /> I certify chat Ifie waste minimization statement Idenggad In 46CFR 282.27(a)Qf I am a large quantity generator)or(b)(ifl am a small quanlily generalpr)le kW. ' <br /> Generelais)0 erar!sPdnted/TypadNeme <br /> : . � •• Signature._ - ..( <br /> 5� ,�Cc' f Mlautih .ay'; Year- <br /> --r <br /> ImpoA b'U:S. --.. <br /> 'Tlapspoitersignature for ex odso ClEtgrat U.3,' Partofenlry/mdt` ) <br /> ( P M) Date teeing U.S. <br /> W 17.TmnsporlerAck6NvfEidgmant.ofRace!ptdfMateriais <br /> kETra,r,,o <br /> �1 Prinied/iyped N Signature _ Mnlh_ DayYenr2 rintedffypedNa Jr _ tGDay- .Year-,. iscrepancy :lr•.• ''ZI- P 18a.Discrepancy IrnSpaca ❑ ❑Residual Parllalfte*t1daQptlR18b.Wlema a Facility(or Ggneralor) ManifestReferancaI <br /> V t <br /> s . U.S.EPA ID Number <br /> ua. FadliVsPhone: 40 <br /> r19. <br /> 3lgnalure of Altarnale Fa ,Y(or Generator) <br /> Iiezardous.Waste Report Iyanegemenl MethodJul <br /> l)odee(I.e.,idea tothaiafdoue tvasta treatment disposal;and renyct�rg eye) :,•,.: ! <br /> 2. 3: fJ4. <br /> jrP!nI=e:dJTYp6dNam <br /> DnatedFacgity0wneror0pemla CerBAcatbndracelptolhssmdous ". <br /> - . ° fed 4Y91amenlfestexcaptasnotedI l • 18a <br /> nota x. ALU l-C�'�' . . n Day- <br /> :edlaoneaipobs*tb. U:� <br /> ta <br /> DES►QN. TED"FACILIY'Y;TO GENERATOR <br /> �. :.. <br />