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Please print or type <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />leenArateauner 3 0 8 6 8 2 7 2 Pay 1 of kimpit6irpanse Phone <br />rorrn Approved. UMti NO. 2050-0030 <br />4. Manifest Tracking Number <br />019703796 JJK 5.BitirtiorRaiwaroglogg Address BReeijorFUltfaritscti6different than mailing address) 4200 Dean Rd 748 S Union Rd FortWorth TX 76106 Stockton CA 95205 <br />B 0 0 7 9 5 - 2 0 7 3 Generabar's Phone. I 6-F-ableretvitigiebntal Services (rd. %A 'otter._ o 3 8 6 6 7 9 4 <br />I 7 Transporter 2 Company Name U.S. EPA ID Number <br />I a lleitatethritlecnerst f14111rea,. : US . EPA ID Number 3525i Oki Skyfinefitrd. #4 , <br />Kettleman City CA 93239 <br />650 386-0711 Facility's Phone 'CAT 0 0 0 El 4 6 1 1 7 <br />ga Bb U.S DOT Desolation (including Proper Shipping Narne Hazard Class. ID Nun-t-,r 10 Containers 11 Total 12 Unit Packing HM and Group (if any)l <br />I tAZARDSUS WASTE, iftIONACRA 301:10 No Type Quantity WtiVol 13 Waste Codes <br />g (BALLAST ROCK lAf CALCIUM HYDROXIDE) 15 181 <br />al I.§ 0 0 1 CM 1364428b Y <br />z <br />us <br />CD <br />2 <br />3. <br />4 <br />I4P1/6tittg evArsifee'ni—at- J013# 11-20-00481 <br />Bo 'S "S"+-1 Always wear appropriate PPE when handling waste. JOIlitil_ 2.4 _00 4 31 <br />15. GENERATOR'StOFFEROR'S CERTIFICATION: I hereby declare that the contentu of this consignment are fully and accurately described above by the proper shipping name, ant are classified, packaged. marked and Labeled/placarded, and are in afi respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Pnrroy Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Adoiowledgment of Consent <br />I cannily that the waste minimization statement ideraeci in 40 CFR 262.27(a) ' if I an,a large quantty generator ) (if ' am a small quantity generator) is true <br />GeneratorslOff era's Printed/Typed Name Signature <br /> ° ibl.7. r-st4 sr- 'q_ syk.k\--k4 I <br />Month Day Year — z....k-S,b 1‘... I ?-1-1-b -a _j <br />I— <br />16 me . Intemabonal Shipnts In importt u.S. EJ Export from U.S ort of entrytexi!: __. <br />-?.. Transporter signature (for exports only): Date leaving U.S <br />ce <br />tai Transporter Acknowledgment of Receipt of kAaterials <br />51— <br />1:-1-2 CT) <br />Transporter 1 PnntediTyped 'lame Sign Monti Day Year <br /> gett Meet) (/rdicr 9 LIG-2' I / I 11) I 7 I ea2r z <br />g <br />T porter 2Printed/Typed Name Signature Month Day Year <br />1 III Discrepancy .i. <br />18a. Dscrepancy Indication Space Quantity Type Residue Paal R <br />Manifest Reference Number. <br /> Rejection 17 F:ill Rtjection <br />?: <br />7.o <br />E3 a Li- <br />180 klernate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone. <br />I 2 <br />1— < z <br />18c. Signature of Alternate Facikly (or Generator) Morid• tay Year <br />I I ° (7) LIJ <br />Hazardous Waste Report Management Method Codes (I,e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C:1 <br />1. 2. 3 4 <br />I Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a <br />Pmedityped Neff \am <br /> 000L--- .- • CI,eirQa(\4/ <br />1 Signature <br />I 1415 rD 1 a'll ear <br />DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM