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Ilfi!!!if!lIiil!liiN!!f!lfilllf!!i!!ff!lillflllffiflllflll Iflflllifl <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM MANIFEST 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST f-"AL000397555 m (800)326-1221 <br /> ,en <br /> .9s Name and Mailing Address- <br /> GNbV T I V59 <br /> 10864 TRINITY PKWY 10864 TRINITY PKWY ON <br /> STOCKTON, CA 95219-7226 STOCKTON CA 95219-7226 <br /> Generators Phone: (209)474-9518 GEN: 209088 <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> HERITAGE TRANSPORT LLC — TS HAYWARD <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> f"gie.,CA-, pan Lid, <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> i T i-'-L <br /> ERIT, GE L '14' SERVICES <br /> 284 E STOREY RD 7 T <br /> Cn[-ILIDGE, AZ 85128-9205 <br /> Facility's Phone: (520)723-4167 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers if.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity, Wt.Nol. <br /> i. <br /> rile <br /> 2. <br /> 331: UO02 D001 <br /> 3. <br /> NON RCRA HAZARDOUS WASTE LIQUID, (WATER <br /> BASED PRODUCTS) <br /> 4. <br /> NON—DOT/NON—RCRA REGU"ATED. (ELECTRONill-I <br /> WASTE) <br /> 14.Special Handling Instructions and Additional Information <br /> 44&99-24 2.W13_x!1457945 LDR 3.W14_01457'04 4.W12 0-1458785 <br /> [130146203GT <br /> 15. GENERATOR'SJOFFEROR'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 labelediplararded,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 certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generatoes/OfferoPs Pril Irr ad Name I zitgna re on Day Year <br /> lip-3 loz, <br /> --j T6.InternationaTSI-illarnants <br /> 1:1 Import to U.S. ElExport from U.S. Port of entry/exiL <br /> Trans portersignature for ex oris only): Date leaving U.S.: --- <br /> 17.TransporlerAcknowleadgment of Receipt of Materials <br /> Transporter 1 P yped NameSignature Month Day Year <br /> L— 102�� <br /> !2��A e" 1 I io3 <br /> rn L <br /> ;E Transporter 2 PrintedlTyp6d Name bjgnatu—C—'-"- <br /> 41Month Day Year <br /> e, t(Le 5 1-3 116 1W <br /> 18.Discrepancy (.I <br /> 18a.Discrepancy Indication Space D Quantity D Type El Residue ❑Partial Rejectior, ❑Full R.Jacli.. <br /> Manifest Reference Number. <br /> j= 18b.Aftemate Facility(or Generator) U.S.EPA ID Number <br /> -3 <br /> U <br /> LL Faci&'s Phone: <br /> 0 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> LLI <br /> !R <br /> Z <br /> a <br /> rn 19.Hazardous Waste Repo nag des(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UU! <br /> 1 2. <br /> H141 <br /> 20.Designated Facility Owner or Operator'.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedfryped NameSignature Month Day Year <br /> [31 /419 <br /> EPA Form 8700-22(Re"-0obsolete. DESIGNATED AGILITY TO DESTINATION STATE(IF REQUIRED) <br />