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Please print or type. <br />Form Annroved_ CM3 No. 2050-W39 <br />Crri rouj oAuv-CL (mev. "i& -i o PrevloU9' "mors ars Obsolete. DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM <br />UNIFORM HAZARDOUS <br />1, Genarator 10 Number <br />Z gage 1 of <br />I 3.Emergency Response Phone <br />4. Manifest Tracking Number <br />WANE MANIFEST <br />102361-1-240 <br />JJ <br />5. C�yeyneyrnloes l tmhegano Mallinf& S t t j'afir n III�f?UeVg Generator's Site Address (if different than mailing address) <br />'ra7ll rt 31�t1Z 1f iJf�E;'em ��1 Ices3' [nc. <br />i 5 i S River Fid. <br />Wes sepi-af -*nTo C.? <br />Generator's Phone: n t .2+ 1- 15 7 4 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />R3r`t os Em ironrnent�i Servirss inn. r i :i o Ln 3 W 5 <br />7. Transporter 2 Company Name U -S, FRA Ii] Number <br />S.D�gignated FapilityName and Site Address. U -S. EPA 0 Number <br />fraB L1�*tri rimental Ser f;Ces Irr= <br />1515SR" v--rRd. <br />st Sacraf eofba C :A 9,W1 <br />Facility's Phone: 916 371-5747- <br />ga, <br />9b. U.S. DOT Description (inrduding Proper Shipping Name, Hazard Gass, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Godes <br />No. <br />Type <br />HM <br />and Parking Group [if any)) <br />Quantity <br />1Yt.Nol. <br />4 <br />1. N ON RCRA }' AZAPw <br />170 <br />i�'i <br />+-7: <br />^_ <br />T i <br />(j <br />1 <br />f <br />LU <br />W <br />2• O T[iar^.A HAZA;;`,D 4.e - :-- -AS EE LIQUID i LSE! ,- AW;f` P- --EZE! <br />_ <br />_ <br />t, � <br />3. <br />i <br />4. <br />} <br />14. S` nd rr tclip9S an�atiar <br />r L_ QiL ulL JRG*j 712) 9B2; SED AN71F � � Gf d t , :�c i t� �i � i F <br />f �V <br />15. GENERATQR'SIOFFEROR'S CERTIFICATION; i hereby declare that the contents of (his censignmerrl are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labe€edlplacarded, and are in all respects in proper condition for transport according to applicable international and national govemmen-tal regulations. it export shfpmenl and i am the Primary <br />Exporter, I certify that the contents of this consignment ooniorm to the terms of the attached EPAAcknowledgment of Consent. <br />I cerrtfy that the waste minimization statement identifi in 40 CFR 262.27(a) (if I am a large quantiiy generator) or (b) (if € am a small quanfty generator} is tme. <br />Generator'slOfferoes PrintedlTyped Name Signature Month Day Year <br />/�(/ <br />16. International Bbipments <br />❑ Import to U.S. Pert <br />Export from U.B. of entrylexit <br />transponer signarura ftor exports only}: Gate leaving U.S.: <br />W <br />Uj <br />17. TransporterAcimowledgment of Receipt of Materials <br />Transporter 1PtintedlTypedName Signature Month Day <br />�r7 <br />Transporter 2 PrintedlTyped <br />Name Signature Month Day Year <br />F- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Fult Reiaction <br />Manifest Reference Number: <br />186. Aftemate Facility {or Generator) U.S. EPA (b Number <br />Facility's Phons: <br />UA <br />16c. Signature of Altemate Faciltiy (or Generator) Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous wasta treatment, disposal, and recycling systems) <br />p <br />1. j <br />�j'J'"r1 <br />2. <br />21 Designated Facliity Owner or Operator: Certification of receipt of hazardous materials covered by the manNest except as d in Item 18a <br />Nnted Name Signature Month Day Year <br />h 1 Lot- <br />I — —/� 0 11 aal <br />Crri rouj oAuv-CL (mev. "i& -i o PrevloU9' "mors ars Obsolete. DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM <br />