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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Attorney Client Privilege/ Attorney Work Product Form Aooroved. OMB No. 2050-0039 LrA t-Orm 1JrUU-Z2 (Kev. 3-U9) Previous editions arNbsole�. C)ESIGNATEr) FACILITY TO DESTINATION STA7E (IF HEOIJIiIEr)) UNIFORM HAZARDOUS 1. Generator ID Number 2. Page1 of . R envy as se Phone 4. Manifest Tracking Number WASTE MANIFEST C A C 0 0 3 0 3 5 1 9 7 1 18851104 J J K 5. C& e[-jjL1lerne BndMailing Address GeneldtptSSife Addre, s (f different than mailing address) 520 CAPITOL MALL 151666 MkheN Road Sacramento CA 96814 Manteca CA 96336 Generators Phone: 9 1 6 596 - 0 8 16 6 Tr nsportef 1 Coman Name U.S. EPA ID Number Amenc an fn�eQrsted Services. Inc. C A R 0 0 0 1 4 8 3 3 8 7. Transporter 2 Company Name U.S. EPA ID Number I c Ekv ( vU -a (4 i OVD 1(-O�q 8. �y Na nd gits Address U.S. EPA ID Number 6r i"T . Incl. 11630 . 17th Street Long Beach CA 90813 Facility's Phone: 562 432-5445 C A D 0 2 8 4 0 9 0 1 9 9a, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any))13. Quantity Wt./Vot, Waste Codes No. Type 1.Non-RCRA Hazardous Waste LWO fused Qig 221 O cqi DM S G - -- z 2 W ra 3. 4. 14.1WgIlliarldlipj Spr on dk fjl�IIj!pa�ojf`�linq. Weightc or volumes are approximate. ee EE�� kk wt1 r U �� g ATS Job#79006-38-1 / C&O Profile:90169 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, and are dassified, packaged, marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable International and nallonal governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 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) is true. Generatoes/Offerors Printed/Typed Name Signature Monlh Day Year Aon I j Z 16. International Shipments 11 Import to U.S. ❑ Export from U.S. Port of entry/exit: — Transporter signature (for exports only): Date leaving U.S.: w 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedfTyped Name Signature Month Da Year CL 0to A0,610 1 z �9 z Tran er 2 Printed/Typed Name Signatu Month Day Year vt e� r� 18. Discrepancy 18a. Discrepancy Indication Space El Quantity U Type ❑ Residue ❑ Partial Rejection ❑ Ful Rejection Manifest Reference Number, 18b. Alternate Facility (w Generator) U.S. EPA ID Number _J V rai Facility's Phone: w 18c. Sgnature of Altemate Facility (or Generator) Month Day Year 4 2 N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. I 'I 2. 3. 4. 20. Deslgna ad acili Owner or Operator. Certificatl of receipt of hazardous materials covered by the manifest except noted in Item 18a Printed/Typecl N m / UM Signature Month Yee Day LrA t-Orm 1JrUU-Z2 (Kev. 3-U9) Previous editions arNbsole�. C)ESIGNATEr) FACILITY TO DESTINATION STA7E (IF HEOIJIiIEr))