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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) DTSC. 04 5 5 3 . -- - Form Approved. OMB No. 2050-0039 GENERATOR UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number if CAS111111039 I Pre 1 of 1 3. EmergendrResponse Phone 800-424-9300-PCCN 4. Manifest 0 Tracking Number 1 7 6 1 4870 JJK Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) San Joaquin County Environmental Health Dept. 4898 Live Oak Road 1808 East liazelton Avenue - Lodi, CA 95240 Stockton, CA 95205 Generators Phone: 209-953-6211-719 1 Transporter 1 Company Name U.S. EPA ID Number PARC Specialty Contractors I CAR000159665 Transporter 2 Company Name . U.S. EPA ID Number Steri cycle Specialty Waste Solutions Inc. I MNS000110924 Designated Facility Name and Site Address U.S. EPA ID Number M-9-21f,ighitileC. PAARRRAR44.V nglewood, CA 90301 Facility's Phone: 323-77641233 . ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) No. Type Quantity Wt.Nol. 13. Waste Codes .r X 1. , UN1992, Waste Flammable Liquids, Toxic, N.O.S., (Hazcat), 3 (6.1), PG 1 DM 20 G 343 0001 • II, RO (0001) . , -, X 2. 1JN2926, Waste Flammable Solids, Toxic, Organic, N.O.S., (Hazcat), 4.1 2 DF 100 P 352 0001 (6.1), PG II , 3. , 4. , 14. Special Handling Instructions and Additional Information ERG#s in order 131,134- ERG book in cab -Wear appropriate PPE when handling 1(1x55) , 2(2x55) ERER# 2018-01-03 - Job*, 368031 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 dassified, packaged, 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 lam the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 26227(a) (if tam a large quantity generator) or (b) (ifl am a small quantity generator) is true. Generatorsi3Offersrs ,ntedfTyped Name Signature _ Month Day Year NI 14-• L-4 A fe r j• - • - 4e-f,•4_t______ I / 1 0 1 i g 16. International Shipments El Import to U.S. Export from U.S. Pod of entry/exit Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER' 17. TransporterAcknovAedgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year I, -----)1A -1 .'Jn-..Ailt-Z. I 1 1 1 4 1 f<3 Transport er 2 Printedrrl Name Arr C-iaidskQS Sig re - MOnUi Day Year 01k9, I/A DESIGNATED FACILITY / . 18. Disrepancy c Discrepancy Indication Space Li Quantity Type El Residue Partial Rejection ElFull Rejection ' Manifest Reference Number: Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: . S I Signature of Alternate Facility (or Generator) Month Day Year 19. Hazardous Waste Report Management Method Codes (i.e., codes kg hazardous waste treatment, disposal, and recycling systems) 1. 114 _ 2. M II/ 3. 4. 20. Des ated Facility Owner or erator. • cation of receipt of hazardous materials covered by the manifest except as noted in Item 18a P ' led ad Name abit-o . Signatu 14 Mo§lh yeau, gn 1 I 0--21X EPA Fotrn 000-22 (Rev. 3-05) Previous editions are obsolete. DEIGI4ATED FACILITY TO DESTINATION STATE (IF REQUIRED) 12905.2144