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<br />Pleas print or type. (Form designed for use elite (92 -pita. ,ewriter.)
<br />Form Approved OMB No 2050-0039
<br />UNIFORM HAZARDOUS 1 •
<br />an ors as apmp perro�'s�irr and will accept the waste the generator is slwpping.
<br />WASTE MANIFEST
<br />Generator I ber 1�
<br />2. Plage 1 of
<br />3. Emergency Response hone. anifest Tracking Number
<br />000971181
<br />r,2
<br />' 483-371 F L E
<br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address)
<br />Central VvilleY Waste Systems
<br />.San Joaquin County Solid Waste Divis : PO Box I810 1333 East Turner Road
<br />Stockton, CA 95201 Lodi, CA 95240
<br />Generator's Phone: 209 458-3ffla ATTN: Kiftra 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 />SST �r� r �/'P
<br />ite Ad�r�s {/�/U.S. EPA ID Number
<br />��bf•�,r�7"!of�.
<br />Ps,nd.
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<br />Le j4aK.U.S.
<br />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 />Wt.Nol.
<br />1 P k�!}AMAFt! F i iCai llfSe; 1"f lti'6t Al _ i lei l H!?It+J S i �! , {fqC�P
<br />612
<br />0
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<br />(HKIM) , :3 ,(13.1), UN 1992, PO II
<br />1
<br />Z2O`�IDIZI�fC
<br />LIQUID, N.O.S., I'SODIUM PERSULFA.TI~,LITHUM
<br />612
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<br />1':
<br />HYPOCHLORITE) , 5. 1, UN3139, P+a N
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<br />3CORROSIVE UQUID, ACIDIC, INORGANIC, N.O.S-
<br />612
<br />X
<br />iHY DRO HUORIC ACID, SUU=URIC ACID) , 8, UN3264, Pr, 11
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<br />4. - . , x, C, C.. ,y N.Q,5, t ' . ACIL),
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<br />OXAL1C A( --ID) > 3, UN 265. PO 11
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<br />14. Special Handling Instructions and Additional Information 1. CH2 2 . 5,516 -I!R1-;RFI3-r- 3 CH240626 01 4�( l"
<br />2. CH24015333XSs IRROOM4 �-- 4. Ch1M29 A",6019a7k.55AP
<br />15. GEN ERATOR'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 labeled/placarded, 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, l certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent.
<br />I 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 />Gene torVofferor's Printed/Type Signature Month Day Year
<br />F-
<br />16. International Shipments
<br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit:
<br />Z
<br />Transporter signature for exports only): Date leaving U.S.:
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<br />17. Transporter Acknowledgment of Receipt of Materials
<br />Tran porter 1�PrriinntedlTypeedd Name �/ Signature --� r ��'• Month ay Year
<br />Q
<br />Tra pgrter 2 Pnnted/Typed t}e6 Signature ,, ' , / i; % Month Day Year
<br />18. Discrepancy
<br />18a. Discrepancy Indication Space El Quantity Type j
<br />❑ T e ❑ Residue ❑ Partial Rejection ❑.Full Rejection
<br />Manifest Reference Number:
<br />181b. Alternate Facility (or Generator) U.S. EPA ID Number
<br />J
<br />U
<br />Q
<br />LL
<br />Facilitys Phone:
<br />LO
<br />18c. Signature of Altemate Facility (or Generator) Month Day Year
<br />;.:
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<br />Q....,•,.
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<br />N1k
<br />Hazardous Waste Re port.Madageraenf MetF 66CS`des (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
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<br />1.
<br />2.
<br />3.
<br />4.
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<br />20. Designated Facility' Owner or Operator: Certification of receipt of hazardous materials covered by them i st except as noted in Item 18a
<br />edfryped NarTj& I re Month
<br />� Day Year
<br />EPA FbtIVS-22 ( 2�-&-cl55 rjwou editions are obsolete DESIGNATED FACILO G
<br />ITY TENERATOR
<br />an ors as apmp perro�'s�irr and will accept the waste the generator is slwpping.
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