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III IIII III II I IIIIIIII I Illllllillllll <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAXAROt3US 1.Genoralor 1D Number 2.Page 1 of 3.Emergency Response Phone7001523437VES <br /> Manifest Tracking Number <br /> WASTE MANIFEST CAR 0 0 0 2 6 6 2 4 7 �2 1s77)91a 0087 <br /> 5.Generators Name and Mailing Address YUL19SA GALVAN Generator's Site Address(if different than mailing address) <br /> FED EX GROUM BALI& <br /> 5655 HOOD WAY <br /> TRACY,CA 95377-7217 <br /> Generators Phone: 2D9 SW2W <br /> S.Transporter f Company Name U.S.EPA ID Number <br /> V130I,TA EB TICAL SOLUTIO 48 N I D 0 9 0 6 3 1 3 G 9 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> TRISTATE l+tC7 TM TRA24M 00. M 0 D 0 9 5 0 3 a 9 9 0 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> VEOLIA FS Ti�IIC.A1.BO1..<J1'ICJNB, <br /> Li.C:. <br /> 1704 W.FIRtC1 STRIES'T <br /> Fadliys Phone: 426 334-5117 AZM&CA 91702 C A D 0 0 8 3 0 2 9 0 3 <br /> 9a, 9b.U.S.DOT Desrxip5on(including Proper Shipping Name,Hazard Class,ID Number, 19.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. i'"&RiCRAHAZARDILKA WASTEIIlMM (COPltEIR.WB, tot <br /> o FC 9L,7T]RIxM8,MCS,611101C,PLATEC.M) <br /> 1 C F 3 F <br /> ur <br /> 2. <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Informa4on 1st Serwke Ca*ulAd by VEM + CUWrW mtaltwd rs <br /> nc' wthaeitf an initiel ftmPotttr to am or M*Ofi *046(kxw kaImpau¢s on rwmkaft behi + t)w.71503 A: <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION; I hereby declare that the eonients of this consignment are fully and accurately described above by the proper shipping name,aril are classified,packaged, <br /> marked and laboledlplacardad,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 cements of this consignment conform is the!arms of the attached EPAAcknowledgmont of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(x)(if I am a large quantity gonerator)or(b)(If I am a small quantity generator)is loco, <br /> General Offerors Printed/Typed Name/ S n Month Day Year <br /> In�. VY t ►\ tK 10 t It 2 12 1 <br /> j 16.Intilmatlonal Shipments <br /> ❑import to U.S. ❑Export from U.S. Part of antrylexll: <br /> Transporter signature(for exports onIy): Date leaving U.S.: <br /> Cd 17.TransporterAdmawladgment of Receipt of Materials <br /> LU <br /> Transporter 1 Prinledlfyped Name Signature Month Day Year <br /> a JOEL SE AS H1 I rveoi IV.1 10 t It 2 12 t <br /> 3 Transporter PrIntaTypedName Signalure Month Day Year <br /> smy-tiLk- M. ' I 1 1 N 12.1 <br /> 18,Discrepancy <br /> I$a.Discrepancy Indication Space ❑ Quantity ❑TypeI0 ) <br /> ❑Residue ❑Pafial Rejection ❑Fu41 Rejection <br /> i <br /> Manifest Reference Numbor; <br /> 18b.Allemale Facility(or Generator) 11' E 1 C TO W'n OVV U.S.EPA ID Number <br /> s m5. H6Mt,OY 51-aeeT <br /> a <br /> FacilillrsPhone; rzIr.NM6NDrCA °fWSCg1 CATORoo �yQ1� <br /> ri � �� -22�� - <br /> LU 18c.Signature of Alte/rna�te Fadity(or Generator) Month Day Year <br /> 1 IL <br /> z 'TCT) h'f7� <br /> 19.Hazardous We aped Management Method Codes(Le..codes for hazardous waste treatment,disposal,and recycling systems) <br /> Gy 1jA*141 2. 3. 4. <br /> 20,Designated Fadkty Owner or Operator:Ceroka of receipt of hazardous m erials covered by the manifest oxce t aVqd In Item 18a 02 4L t <br /> Print y NameAs-, jil o x.S f� <br /> I <br /> EPA Form 700.22( .12-17) FIlreflougleditionsiire obsolete. DESIGNATED FACILITY T11 EPA's e•MANIFEST SYSTEM <br /> a <br /> I <br />