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PteaSe pfinter <br /> " � � II � Fain Approved,OMB ND.21)50-W39 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page]G:,0126-m <br /> rgency Response Plane 4.IMinhal TwIdN Numbar <br /> WASTE MANIFEST VES <br /> 5.Generators Name and Mellkg Addroes s S8e Address(if diff I than mai"address) <br /> YULISSA GALVAN <br /> FED EX GROUND SAME <br /> 5655 HOOD WAY <br /> aCrYPA 95371.7717 <br /> 6.Transporter 1 Compemy Name9 929 11469 U.S,EPA ID Number <br /> VEOLIA ES TECHNICAL,SOLUTIONS N 3 D 0 8 0 3 <br /> 1.Transportar 2 Company Name U.S.EPA ID Number <br /> 8.Designated Fediily Name and Site Address U.S.EPA ID Number <br /> VEOLLA ES TECHNICAL SOLUTIONS, <br /> L.L.C. <br /> 1175 HENSLEY STREET <br /> tsar sPtane: RICHMOND,CA 94801 C A T 0 6 0 0 1 4 0 7 <br /> 99. 9b,U.S.DOT Desv'sption(Including Proper SNpplrg Name,Hazard Class,0 Number, 10.Containers 11.Total 12.Unit <br /> and Packing Group(d any)) 13,Waste Codes <br /> HM No. Type Quantity WINot, <br /> $c 1' NON-RCRA HAZARDOUS WASTE LIQUID, (SILICONES. 331 <br /> 2 D F 323 P <br /> All <br /> 2. <br /> C7 <br /> 3, <br /> 4. <br /> 1a,spedai Handing rmstructioms and Additional InJormatiMER Service Contracted by VESTS + Contract retained by generator <br /> $M jffify authority on initial transporterto add or substitute additional transporters on generator's behal�E -I. 1)W:71579 X- <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I herebydoclate that the contents of tbls consignment are fully And accurately described above by the proper ehipp4g name,and are classified,packaged, <br /> marked and labeledlplocarded,and are In all respects In proper condition for transport amending to applicable Intemationatand national governmental regulations.If export shipment and I am the Primary <br /> F_xportar,I aartlfy fhat the contents of this consignment conform to the terms of the anKted EPAAckraMedgmant of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(g I am a Large quantity generator)or(b)(if t am a small quantity gaaerntor)is <br /> GerteratorsJOfferera PrintedlTyped HamaSignature Month Day, Year <br /> 16.Internoral S pments <br /> import to U.S_ ❑Export from U.S. Port of entrylexh <br /> Transporter signature(too exports only): Data leavhg U.S.: <br /> 17,TransportarAckn wfedgmant ol Receipt of Mat riaks <br /> 1 PdnledfTyped Sig Month Day Year <br /> O <br /> Transporler2 PnntedJTyped Name 5(gnature Month Day Yes <br /> uudGG 16.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Q,.* ❑Type ❑Residue ❑Partlal Rejection ❑Fund Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> +�+ Facil tys Phone. <br /> 18c.Signature afAtternate Facflgy(a Gerteratar) Month Day Year <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste trestment,disposal,and recycling systems) <br /> 4. <br /> l <br /> 20,Designated Facility Owner or ,0paretor.Codittien of moelpt of hazardmm mamrtaig covered by the maNfest except as noted in Item 18a <br /> PrinWyped Na nature Month Day Year <br /> EPA Form 97oo-22(Rev.12-17) Previous ediUonsare obsofate. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br />