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Plea:ejirint or type. <br /> 2-1 <br /> # B33K NERATOR ). FormAppmed.OMBNo.2050-01 , UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1, Generator ID Number <br />C A C 0 0 3 0 9 8 8 7 <br />2 Page 1 of <br />1 <br />3. Emergency Response Phone <br />8444444484 <br />4. Manifest Tracking Number <br />021952048 JJK 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address <br />Kiiiik 0444iNFEST PGiliE CitTP I-44W RIPON PO 90X MO 371001 -121r0005 SAN FRANOISCA (A 6412i) 1 MODESTO GA On% Generator's Phone: <br />l' 1 $ 0 6 1 - 0 0 0 6 6 Transporter 1 Company Name <br />U.S. EPA ID Number <br />P!..1r q4IKKINTRAI-- CU .I.RnAiFtrtiKi (. Pi 41AFian 0 9 Fi P A /4 Transporter <br />Sta <br />2 C4ompany Name <br />t OP U.S. EPA ID Number Oarfe ColutioRS 1 rnn6cublloci2-14 Designated Facility N m d Site Address <br />Facility's <br />U.S. EPA ID Number <br />GEM 01' ROOK;iihj WHAM" LIA.:; ilea Wign KICK FiCAO <br />RANI;:t-40 CO 1;tDO# C.ik *742 <br />Phone: tr,..1 4, Ar <br />ga. <br />jim <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if any)) 10 Containers <br />A- <br />11. Total <br />Ci $) 4 <br />12. Unit <br />0 a 8 4 1 a 3 <br />No Type Quantity Wt.Nol. 13. Waste Codes <br />1 <br />NON RGRA HAZARDOUS WABTE, SOLI) (801LJOERRIS <br />(ONTAMINATEll wrrH (11L.DIF_EIELA4O tirERCAPTAN) <br />0 0 1 OM 00500 <br />14 Special Handling Instructions and Additional Information <br />116-1910-0000-,70375 <br />9B-1) 492061 SOIL/DEBIS CONTAMINATED WITS OL-J, DEBRIS AND MERCAPTAN 1X55 <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, at 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 EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) <br />Generator's/Offeroes Printed/Typed Name Signature Month Day Year 044 M_HAIS OF _PriSE: ROO (.141j!sERT I _...--5-- I S. International <br />i— <br />1 <br />.. <br />Shipments <br />L <br />/ <br />Import to U.S. <br />Li Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: — !D FACILITY 'TRANSPORTER _ j 1' Transporter Acimowledgment of Receipt of Materials <br />Transporter 1 Pni:ited/Typed Name Signature __,,f9: ,,,... Month Day Year RCA GILBERT <br />er Ace-0 142 , r 2 3..riaed - 1 i golfi- Name 10 <br />irliw- OF <br />illir <br />Month Day Year <br /> <br />S._ 1 i 1 I qi 21 18. Discrepancy <br />Discrepancy Indication Space _ — Quantity 1 I Type H Residue Partial Rejection Full Rejection <br />Manifest Reference Number: Alternate Fadlity (or Generator) <br />U.S. EPA ID Number <br />Facility's Phone: <br />Signature Iu <br />I— ct z <br />52. <br />of Alternate Facility (or Generator) <br />Month Day Year <br />I I cn 19 <br />al 1. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C3 <br />If+ <br />12. 13. 1 4, <br />20. Designated Fac lity Owner or Operator:Certification <br />Pitted/Typed Name <br />of receipt of hazardous materials covered by the manifest except as ncted in Item 18a <br /> , fik6e-Av Signature <br />01;d4/1 1 qlf041* Month Day Year 1 n-)1'2 r2,1 - . - revious editions a bsolete. <br />SIGNATED FACILITY TO EPA's e-MANIFEST SYSTEN