|
FEB / 25/ 2022 /FRI 04105 PM Tracy Truck Stop FAX No , 209832 2312 P1005
<br /> �� --
<br /> please print or type: Form Approved, OMB No. 2050.0039
<br /> UNIFORMIWAZAR' DOUS 1 . Gengralor` D Number ' 2. Page 1 of 3: Emergency RC�e once Phone an St aC U n j
<br /> WASTE MANIFESTM I �,
<br /> 5. 6�neratQ[ S a�ney3r Q�1 ,AJr{y�ress • Generator'sSiteAddress (ifdifferent then ,rpsilingaddress)
<br /> r ��o -• • . ca; s
<br /> 1:0 IIIItIn",P
<br /> Generator's Phone:
<br /> 6. TTnaporter 1;Company Name U.S. EPA ID Number ;
<br /> 7. Transporter 2 Company Name U.S. EPA ID Number
<br /> Facility's Phone: =;^r at i icAPOy
<br /> gQ 9b. U.S. DCT Description (Including ProperShipping Name, Hazard Class, ID Number, '10: ContalnaYs 11. Total 12, Unit 13. Waste Codes
<br /> HM and Packing Group (if any)) No. Type Quantity • Wt.Nol.
<br /> LN '.. .OW ad . :3
<br /> w 2,
<br /> t c9
<br /> 11
<br /> 3.
<br /> 4,
<br /> 14, Spacial Handling Instructions and Additional Information • /^f�/� / ` `-
<br /> Y
<br /> 15. GENERATOR'SIOMROR'S CERTIFICATION : I hereby declare that the contents of this consignment.ers fully and accuraI described above by the proper zhippind name, and are classtFed , packaged,
<br /> marked and labelediplacarded, and are in all re9peota in proper condlion for transport according to epplloeble Intematlonaia d national governmental 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 certifythatVte waste minimization statemant identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) (iN am a smell quantity generator) Is Vue.
<br /> ,
<br /> ..
<br /> iingrators/OHgror'SPrinted(TypedName Sign$tur; Month Day Year
<br /> t.
<br /> 16. Internatlonal Shipments r
<br /> �. I, ❑ Import to U.S. ❑ Export from 'U.S. Port of en y/exit:
<br /> z Transporter signature (for,exports only); .: Date•leaving U:&:
<br /> 17. TrensporterAcknowledgment of Receipt of Matedals
<br /> Treli14romt bl9A LTIi .kped N mb Signature tee Month Day Year
<br /> 0 re
<br /> Transporter 2 Printed/Typed Name ( Signature Month bay Yaar ' '
<br /> 18. Discrepancy
<br /> 18a, Discrepancy IndioR ton Space ❑ QUant
<br /> fry ' [] Type ❑ ReaidUe El Partial Rejection El Full Rejection
<br /> Manifest Reference Number.,
<br /> 18b: Alternate' FaCility( or 'Generator) ID U•S•;EPI� NVmb'er
<br /> ..t I .
<br /> Facility's Phone:
<br /> 18c. SignaM 7f Xltarnste Facillry (or Genprator) : ,I, 21 4, Month ; Day Year
<br /> 19. Hazardoua Waste R ort Mahagement Melliad Codes (i.e:; 44for h2zardous t4as(dTreatment, disposel, and recyoling' syMSM5)
<br /> 121
<br /> OP
<br /> ! hr.
<br /> 20. De ;igna(edt.Fsollity Owner or Op rator. Ce o tion bf receipt of hezardoU9 materials covered by the manifest except as orad in rpm 18a
<br /> Printed/Typed ��Na ,r ' Signstur .,a,,, M De_ / pr{ ,y Yea
<br /> EDAF,,.m a7nn 12 a -,t n.,.,'a... ,,, dr r.. -
<br /> E �.)
<br /> Received Time Feb , 25 . '.e2022�tr 4 : 04PM., No , 7114. .. .., GENERATOR " .l � G�
<br /> DESIGNATED FACT TY.. TO �,
<br />
|