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Please print or type.(Form designed for use on elite{12-pitch}typewriter.) Farm Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number 1 2.Page 1 of 3-Emergency Response Phone 4.Manifest Tracking Nu b r WASTE f>BANlPESr C A a 9 8 2 0 3 0 2 D 7 1 SM87'7'-7267 018853797 (6�J�]l 88 SS Jc 1] JJ K 5.GUltiri(ator S1VaCK Waa '� ss G+<n rg atod�„Slte Addre�s(' diffe t than mailing addess} EE�11�tt OOORR�ouffisfflss Sit W Stop 1030 � Ll��l E ft StG et. Shu NE 88179 Stockton CA 95206 Generator's Phone: 9 1 6 540 - 0 4 9 6 6.Transporter t Com any Nae U.S.EPA 11)Number America � mritegmted Servkt s,Inc. G A R U 0 0 1 4 8 3 3 8 7.V. Le. porler 2 Company Name U.S.EPA ID Number ',n S C�Da 8.DiF na ed 1`0=d a and fileeAAdd ress U.S.EPA ID Number IM W.I-M stat Long Beach CA X13 09019 Facility's Phone: 662432'540432^ 0 4 9a, 8b.U.S.DOT DeWiplion(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12_Unit 13.Waste Codes HM and Packing Group(if any)) No_ Type Quantity Wt.Nol. X 1 X120,MSTE GOWNW,3,PGI F 331 l001 D018 01 .BM 5 G M x 2.LWIM MSE POIrslt Re1�d MOWFIBIA M 331 DWI 01 DF 5 P a.[!W810,Tbxk,Nq�,argaric,nzAL,(DlIquat Diftorttle� 331 X I80tr'rop*111fl r►s salt OfCAV hosde),6.1,Poll Of OF p __ 4. 221 [HILI �j 0 14,Jpf0 lin Vongul�q�` (if r on gF e❑ ndlintq waste■ Weigh4tn or volumes are approximate. 9b I- Prof3.le # i 1' � 9b.3) Profile #U75�i.�1 Pro eat #79023- vet 2 4 �� 9b.. Profile #(-'� y l it l 9b.4) Profile #V17 111fJ 15. OEM ERATOR'SlOFFEROR'S CERTIFICATION: I hereby dedore that Ihp contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and iabeledlplacarded,and are in all respects in proper condition for transport according to appllcable international and national governmental regulations.If export shipment and I am the Primary Exporter,l certify that the contents of this oonsignmenl conform to the terms of ft attached EPAAcknowledgment on t. I certify that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(}(if al(quantity ener or)is true. GeAtte.510OHPrint d �er, /TTyied ame Sig ure Month Day Year �r t naratar J.HougWOV -J 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(for exports only): Date I ving U.S.: 17.TransporterAcknowledgment of Receipt of Materials LLITransporter 1 PrintedlTyped Name Signature Month Day Year Vlk QTrrter2 PrintedlTyped Name Signalur Month Day Y b 1 18.Discrepancy 18a.Discrepancy indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J tea. Facility's Phone: im 18c,Signature of Alternate Fed lily(or Generator) Month Day Year Q N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste lrealmant,disposal,and recycling systems) (3 1. a 2. jr, 3. 4. y It 20.bosfg,ahed Facr ity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted i lem 18a Printed(T ped ame Signat Month Day Year EPP Form 000 ,3-05) Previous editions are obsolete. D ESIGN FACILITY TO DESTINATION STATE (IF REQUIRED)