Laserfiche WebLink
� Please print or Form Approved.OMB No.2050-0038 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone4.MenIf" Traekiny Number__j <br /> /� c <br /> WASTE MANIFEST C A R 0 0 0 2 6 6 3 1 7 1 (ti7'ar}41><-0067 ©O 1801114 VES <br /> 5.Generators Name and Mailing Address Y1MjM GaVAN Generator's Site Address(04threnl than n*ling address) <br /> FID}E1C C�{1C1�i11 SAMA <br /> 5655 BE=WAY <br /> TRACY,CA 95377-7217 <br /> Generaloes Phone: 209 13044 <br /> B.Transporter 1 Company Name U.S.EPA ID Number <br /> VEt=N8' 90LV13" IN 7 D 0 6 0 6 3 1 3 6 9 <br /> 7.Transporter 2 Company Name U.S,EPA ID Number <br /> 8.Deslgnaled Facility Name and SileAddres.VEMM 11$MXWWALSOLU11f, U.S.EPA ID Number <br /> LLC. <br /> 112$HIOW1EY S18Eff <br /> i Fadis Phone: SIO 433.60D1 RXMMMW,CA 94301 CAT 0 8 0 0 3 4 0 7 9 <br /> go. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Numbef, 10,Containers 11.Total 12.Unit 13,West&Codes <br /> HM and PaWng Group(if any)) No, Type Quantity WtNol. <br /> 1 NIM "GAA SAZA11WOUS WARM UQIHD,(LATHK PAU TI' NONE <br /> 1 D F 2 3 9 P 331 <br /> z 2. <br /> LIJ <br /> 3. <br /> 4, <br /> 14.Special Handling lnsbtrctim and Addittonal lnformt on ER8wvkvCM&w6WbyVEM + Comm el nd by pwa to waft t <br /> �1 ty M 101W >al ra to sM orb.�es*Mkk t ole A <br /> bdmk + 1)W.�1529 : <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby dectare that the contents of this consignment are My and accurately described above by the proper shipping name,and are classified,packaged, <br /> ma*od and labeledlplacarded,and are In al 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 oedly that the contents of this consipnmont conform to the terms of the attached EPAAcknowiedgment of Consent. <br /> 1 t certify that the waste minimization slotoment Identified In 40 CFR 262.27(a)(if I am a large,quantity generator)or(b)(if I am a small quarditygenerator)is We. <br /> GoneraloesfOfferoesPrinleNTypedName Swature Month Day Year <br /> 0 2 12 3 12 1 <br /> iB.tntemational ShIpments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAduovAedgmenl of Receipt of Materials <br /> Transporter 1 Printedrryped Name Signature Month Day Year <br /> gWm4y CRIUZ �� 0 212 3 12 1 <br /> Transporter 2 Pdoledffyped Name Signature Month Day Year <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejecdorr <br /> Manifest Reference Number. <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> IL Facility's Phono: <br /> W 18c.Signature ofAllemate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,dtaposal,and recycling systems) <br /> � '. Jf-/ 1 <br /> 2. 3. . 4. <br /> 20.Designated Facility Owner or Operator:Cert1katlon of recelptof hazardous materials covered by the manitest except as noted in Item 18a <br /> n dfryped NomeSignature Monffi Day Year 0.3 1193 Z/ <br /> EPA Form 8700.22(Rev.12-17) Previous editions are obsolete, DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br />