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0077 `� HCl= Ura 2336842 <br /> 853047-16 .DTSCQQ 6bv• V �(��p /- <br /> Please print or type.(Form designed for usebn ehf r(l2� Itch)typewriter.) Llit[- ¢f O ry / Fonn Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I.GeneretoriD Number 2.Page 1 of 3.Emergency Response Phone f4.Manifest Tra119"389 <br /> cfkin Number <br /> WASTE MANIFEST CALOOD413752 1 (877) 577-2669100 0119 3 8 9 DAT <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> ,�Surait RDof,lnq Services Suanit hoofiag Services <br /> 765 Industrial Park ➢rive 105 IDdastrial Park Drive <br /> Generators Phone: Danteca CA 95337 12091025-3042. Nateea CA 95337 12991025-3052 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 21st Century Environmental Hanaaeuent of California. LP CAR000210617 <br /> 7 nsporter 2 Company Name U.S.EPA IDumber <br /> e� \'Wv' '�_ L mer ( e -TXGC'(. o7SU <br /> 8.Designated Facility Name and.Sile Address - - U.S.EPAID Number <br /> 21Sf CENTR Y ERVIROh9RlfTRi GIRMEiffllfT OF WVRPR, LL9 <br /> 2995 KEW-MS DRIVE EAST <br /> Fad sPhone: FEKEY NV91188 17751 575-2159 NVD980895338 <br /> go. 9b.U.S.DOT Descdption(induding Proper Shipping Name,Hazard Class,ID Number, 10.Centsiners 11.Total 12.Unit <br /> HM and Packing Getup(e any)) o. TypeQuantity WVV01. 13.Waste Codes <br /> UN1993 UR4'IE FILL10RE LINID5, N.O.S. XNERK SPIRITS, D89I DON F803 <br /> X 6ASQLIgE) D DSII 8011991=I09t➢SI. 7 DH P 215 <br /> z 2. - 1 . <br /> w Y, <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> (Il 753722-99 - ERSI121) NIXED SCUMS � <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accumt*described above by the proper shipping 0ap2e,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 gmemmental 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 allached EPAAclmovdedgment of Consent <br /> I certiy that the waste minimbabon statement identified in 40 CFR 262.27(a)[d I am a large quantity generator)or(b)(I]=a small quantity gerami is true. <br /> GeneratoesrOfferves Printe/Typed Name Signature Month Day Year <br /> j <br /> /9 / <br /> j 16.International Shtpmenls <br /> r ❑IrryaIt to U.S. ❑Export horn U.S. U Pan of en /exih <br /> Transporter vgnature(for exports only): - Data <br /> le U. <br /> 17.TranspaterAdunowledgment of Receipt of Materials <br /> Transporter t Pdnted7Typed Na^� Sig lure - Month Day Year <br /> y F.sohH s0 1 3 1, 191Is. <br /> Q Transporter 2 PrintedRypedName sigreWre A Month Day Year <br /> Td y z <br /> i18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quant, '❑Type ❑Residue ❑PaNal Rejection ❑Fun Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(a Generator) U.S.EPA ID Number <br /> (k <br /> LL Faalitys Phone: <br /> W life.Signature ofAltemats facility(or Generator) Month Day Year <br /> a <br /> z <br /> w19.Hazanfous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2, 3. 4. <br /> 20.Designated Facility Owner or Operator CeriRrallon of receipt of hazardous materials covered by the manifest except at noted In Item 18e -_--. _ - <br /> +II Pn iTyped Name Signature Month Day Year <br /> 2 1�l f rf �. x 5 r i(,- <br /> EPAFotm87004 (Rev. 5) Previous editions areobsolele. DESIGNATE ATOR STATE(IF REQUIRED) <br /> 191150.17481R' 2 2 2016 <br />