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jo ASSL SK*SHTA#`234964224 <br /> 008029040SKS <br /> Please print or type. Farm Approved.OMB Na.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator Ip Number 2-Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CI~0@0429472 I Gs.,J-=rbti-1 .�a -1008029040 <br /> o 0 4 o s Ks <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> J"Rai Z # ,its11 <br /> 1950 McHenry Ave <br /> ESCALCN `� CA 95320-2081 <br /> Generators Phone W"'838-6384 <br /> 6.Tr erj CompariyName U.S-EPA ID Number J <br /> IN -h!_�t1M SYSTEMS INC TP1 0a <br /> 7.Trimsp"r 2 Company Name U.S.EPA ID Number <br /> CLEAN i•11-iRiL ORS. ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEPN HARBORS GRASSY M01JNTAIN U.S.EPA ID Number <br /> 3 MILES EAST, 7 MILES NURTH KNOLLS EXIT 41, OFF' I_-80 <br /> Fadlitys Phone- 435-884--9915 UTD991301746 <br /> ga 9b-U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10-Containers 11.Total 12.Unit <br /> HM and Parkin up(if any)) 13.Waste Codes } <br /> No. Type Quantity WtNol. <br /> a 1 <br /> 6^2it NON-RCRA HAZARDOUS WASTE, SOLID, 0M P 1,8_1 <br /> (40.ab RFIENT AND ❑I L y, t• "�V.. L �� <br /> NJ ' <br /> = 2- <br /> W <br /> � 9r <br /> I <br /> 3. I <br /> r T <br /> 4- <br /> 14.Special Handling Instructions andAddi[icnal Information TSD.GM 86956Bt6 UR 1CSS <br /> 1 3� <br /> 241 EMI=P.C.ENCY#800-459--1760-CH/S�[I1Fi--Contract retained by gerler��r confers a encyautnor•i4 s <br /> On initial t.rAnsnn+^tar }n ar-Irl nr• cothc{-i i ti+n fldit i nnAf"A5gnnrtPr& rrn nvnev�a� �.,�•f r Kft, ,N t F <br /> 15- GENERATOR'SfOFFEROR'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 labe]ed'placarded,and are in all respects in proper condition for transport according to applicable intemationaI and national govemmental regulations,if e t <br /> Exporter,t oerfity that the contends of this conrrn <br /> sigerd conform to the terms of the attached EPA Acknowledgment of Consent. shipment and 1 am the Prmary <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) it I am a small quantity generator)is true- <br /> GegeralorI <br /> rg Prr dl7yped H, 5 tune Mpnlh Day Year`` if J'�{Int <br /> _j 16.intemational Shipments <br /> P__ ❑Import to U-S. ❑Export from U.S- Port of entrylexit: <br /> x Transporter signature(for exports ony); ' Date leaving U.S.: r <br /> I W 17.Transporter A&nowledgment of Receipt d UNWals <br /> IF- T nsporter 1 Prinled7i me S g Month Day Year <br /> f` � %2 [e(97yped13 Z� <br /> Z Tra Name re <br /> Mont[ Day Year <br /> 18.Discrepancy <br /> 1 Ba.Discrepancy Indication Space ❑ Q.,tity ❑Type ❑Residue ❑Partial Rejection Dull Rejection f• <br /> Manifest Reference Number: <br /> F 18h-Alternate Facility(or Generator) U.S.EPA la Number <br /> J <br /> i <br /> nai Facility's Phone: <br /> t8c.Signature ofAltemate F@aiity(or GenefaWrJ <br /> h LU <br /> F ,. r. Month Day Year <br /> a <br /> x <br /> N19.Hazardous Waste Report Management Method Codes(i-e-,codes for hazardous waste treatment,disposal,and recyding systems) <br /> G 1. 2. 3. 4. <br /> r1� <br /> I I20-Desigfheled Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a O r tI� <br /> Pdnted ypeo Name Signature Month Day Year <br /> I //a/-/— &d I aw I - i q I eb Z f <br /> EPA Form 87DO-22(Rev. -17) P Ions editions are obsolete. DESIGNAtEnF kry TO EPA's e-MANIFEST SYSTEM <br /> IJla�z."a1/40S5�Ew� <br /> s <br />