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44 <br />Please print or type. (Form desig ed for use on elite (12 -pitch, riter.) CJ147,W PP )fes Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone4. Manifest Tracking Number <br />C H 1 1 1 0 0 0 8 5 7 1 (30t]) 483718 00113742 � FLE <br />WASTE MANIFEST >Q <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />County Of San Joaquin - Tracy Mo C Hcitc1+m Ave 5,1414 - <br />5 f ac k 65,1, ( A q5 Zo 1 29"R Sam Trac,' Boulevard <br />969;4 0 Tracy, C'A, %V g6*377 <br />Generators Phone: 209 469,30M ATTN: Kimbra Andrews <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Clean Harbors Env Services Inc M A D 0 3 9 3 2 2 2 5 0 <br />7. Transporter'2 Company Name U.S. EPA ID Number <br />B nated.Faci�(Na e andSnte$Adtdr�e U.S. EPA ID Number <br />�Si <br />11600��N fr0liD�iD Apttus Road UTC) i� 0 1 5 5 2 1 7 7 <br />Gr3.11sville'UT 84029 <br />Facility's Phone: X80 i) 323-810U <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wl.Nol. <br />1 P01-:VCHLORNATED BIPHENYLS,. SCUT) , 0, UN3432, PG III <br />�. <br />012 <br />Z <br />LU <br />z q N DOT REGULAT D MATER) L, ($HA.IR.PS NF Di.ES . f D <br />'40NE <br />3t`,�;1,./L4� <br />4. <br />14 S ecial Handlin Instru ti s an A iti I Information <br />1. pCii2d0 $ 3. C H a. i{t'�lra� / ✓ ,;?('", �a { <br />2. GH221037 <br />OSO 0"2-2007 PCB 100 <br />S0#GJ1492G(k Fleet .0 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labelled/placarded, and are in all respects in proper condition for transport according to applicable intemational and 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 EPAAcknowledgment of Consent. <br />1 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. <br />Generators/Offeror's Printed/Typed /j 1' +- he r,6*%4 ps h Signature on ay <br />ear <br />jName <br />r <br />a 1' ( ti W r J i • Vr 1 � 11 G1 bets !;1461 5u r46s a r7 f v aA 11 t` � ✓'l/l/ 1.� ^ of 6 <br />U <br />J <br />1— <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: <br />Z <br />Transporter signature for exports only): Date leaving U.S.: <br />w <br />17 Transporter Acknowledgment of Receipt of Materials ' ) <br />a <br />C) <br />TransportIr 1 PrintedlTyp ame Mon a ear <br />107 <br />Tran 2 Phnted/Ty'ped�Name Signa re onth Day Ye2r <br />1&, ai�aripaacy . �. <br />1�a,bs¢F8p I'Ri %W QuantityFuII Rejection . <br />uantity :,- LType Partial Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />Facility's Phone: <br />La <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />Z <br />CD <br />19. Hazardous Waste Report- Management Method Codes{i.�, codes-for-hazerdouswa§te4matmeTR, dispoad,,and*cyclhgsysternsp <br />N <br />0 <br />1.2. <br />3. ' •�� <br />` } <br />4 <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manif xcept as noted in Item 18a <br />Printed/Typed Name ( Signature .- Month ear <br />•ev. <br />LrpA For 87 0 22 05) Previo a Itlons are bs tete. DESIGNATED FACILITY TO GENERATO . <br />t"n Bra-rs she rla Pe aiyd will accept file waste the eneratnr is shiPf� _. <br />