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Please print or (vne- <br />Form Aaaroved, OMB No. 2050.0039 <br />tPA corm 610u-2"1(rtev. 12017) Previous editions are obsolete. TRANSPORTER COPY <br />UNIFORM HAZARDOUS <br />1. Generator 14 Number <br />2. Page 1 of <br />'3. Etne(gency Response Phone <br />4, Manifest Tracking Number <br />WASTE MANIFEST <br />C A r., 0 0 3 1 0 , 7 1 gilt <br />41&633-0112 <br />02261,92, <br />7 JJ K <br />5. G n alois Name and Mail i 9 Address ( S Gen ralors Site Address (if different than mailing address) <br />r�0 imel 1_L.(:: H Cs C tyrder, <br />Y _'0m[r1[ MI l mwnerce <br />Lt.(, <br />23'I Lafayette Cit(*, 0200 20�5�0 Hotly Drive. <br />1'[acy CA 94549 - +1� 8 1,95403 <br />J%1,T <br />r �`fi` v1 [ti pN �r ��x)q <br />.y % 9` ti �'7 r �1 <br />Generator'sPhonef ) <br />6. Transporter 1 Company Name " • , <br />,S. EPA ID Number <br />MEN <br />7. Tra sporter 2 Company Name - . , (l <br />U.S. EPA ID Number <br />,{y,1� , <br />Wc.. <br />iY ti <br />B. eBsicn"UFate�C I Na a and Sile Address k� ' ;}•j i IL <br />U.S. EPA ID NymberF . <br />NUN* <br />Facility's Phone: r; " rt , Y,; <br />ga• <br />9b. U.S. DOT Description (including Proper 6hipp5ing N me, 4azard Class, ID Number, " <br />10. Containers <br />11. Total <br />12. Unit <br />13, Waste Codes <br />HM <br />and Packing Group (if any))No. <br />type <br />Quantity <br />WfNol, <br />1 oil-RCR Huzardwt5 Waste, t..igl[ld KY1 & Miter MIXture) <br />223 <br />0 <br />O <br />^t � <br />_ <br />0 Q 1 <br />TT <br />Q. <br />MENREW <br />Z <br />NE <br />2. <br />LU <br />.. . <br />MMMMMMM <br />3. <br />MUUMUU <br />4. <br />6 <br />dditional Intrali n <br />14, )Soacia' Handling InslruClions ar[d �' <br />1 i..l. 1'11. [`I.t. <br />. <br />}tt1V7.['i?tl.(t[r7[)t't1.r IrY'c <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, <br />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 governmental <br />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) (ill am a small quantity generator) is true. <br />Generator's/Olferoes Printedfryped N e Signature <br />Month Day Year <br />IV <br />,UUi <br />16. International Shipments <br />❑ U.S. ❑ Port <br />[Umm <br />Import to Export from U.S. of entry/exit: <br />Z <br />Transporter signature (for exports only): Dale leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />LLJ <br />Transporter 1 Printed/Typed Name Signatuir <br />Month Day Year <br />Z <br />Transporter 2 Plintedrryped Name Signature <br />Month Day Year <br />F- <br />18, Discrepancy <br />18a. Discrepancy Indication Space ❑ Ouantity ❑ Type Residue <br />Partial Rejection <br />Full Rejection <br />Manifest Reference 1recr <br />18b. Alternate Facility (6r'ddneral6r) <br />U.S. EPA ID Number <br />J <br />V <br />Facility's Phone: <br />LOU <br />18c. Signature of Alternale Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />y19. <br />Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) <br />p <br />1. <br />2, <br />3. <br />4. <br />20. Designated Facility Dwne(or Operator: Ce "cation of receipt of hazardous materials covered by the manifest excepl as ncted In Item 18a <br />Printed[Typed Name j Signature <br />- <br />Month Day Year <br />' `,, i t � � t_. 1.� � < <�' ` C � ��...� � U � l-' <br />• ��1 'c. '"' •. �'...! 1, <br />1, � � � [ <br />�.L,� <br />