|
Please print or type.
<br /> UNIFORM HAZAR04US i.Generator tp Number Farm Approved.OMB No.2050-0039
<br /> WASTE MANIFEST �'Pags 1 of 3.Emergency Response Phone 1.ManifestTracking Number
<br /> ^rte, ,:'1 •� t, ,. t.- . JJK
<br /> Generatofs Name and Mailing Address 1 f i f1 r.r, n t1 4 e
<br /> V.Z:- ''rt} E xr,r u M', Goneratots Sila Address(if different than mailing address)
<br /> 7125 Ccr!':::nni,7l �'I,:i � �:r:a L��.r'�, 1"iq 37209
<br /> GeneratoesPhone- �aifi-257-tJn7!? '�:�1--".!3 M Thornjorl rd,
<br /> fi.Transporter 1 Company Name Lodi. Ciq 25 242
<br /> h!n-Gil U.S.EPA ID Number
<br /> 7.Transporter 2 Company Name W. i'�
<br /> U.S.EPA ID Number V
<br /> B.Designated Faality Name end Site Address
<br /> LrC:;i;� �+ �Vt"?1iR311 U.S.EPA ID Number
<br /> t I1E 33
<br /> L0nq VZ'. Ch, CA I
<br /> i Facilitys Phone: (rar" 1 r
<br /> y 14?2-544
<br /> 9b.U.S.DOT Descr
<br /> 9a. octan(including proper 5hpPin Name,Hazard Cass,Ip Number, t0_Contas f,
<br /> , n r,
<br /> HM and Paddng Group(d ay}) fI?:t 'P.!' T•,r g
<br /> 11.Total 12,Unit 13.Waste Codes
<br /> o Pt:rl-I;LF;t,t'}=�ZE.If:J;l3 �t7I'si,'+(nit��I, GoUrl�} ND' Type OuanGty wtAfol.
<br /> D:1 150
<br /> r"
<br /> COIT0i.6S1iblo L1:11ald, n.o-t;,,{ 1/::(��r, Dkwc3},Comb.
<br /> 40
<br /> 3.
<br /> 4.
<br /> -Spedal Handling trrstructV 171
<br /> iorts and Additional Information
<br /> r��n:r:r rtivcrx=4:rt cyr cr=:,�s
<br /> L~ i�1R�T:Wd 1 FT4:S�w.-71i,L:'�i7 C,•J
<br /> nc,;ari:feor„Cser.�._rr- ]CL^ �^-} .••, -,
<br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately de=Ded above by the , ,
<br /> marked and labeledlplacarded,and areln all respects in proper condition for transport according to applicable intemationaland national govan�ental regurl tions.Ili export shipment and I am the Primary
<br /> packaged,
<br /> Exporter,I certify that the oontents of this consignmenl conform to the terms of the attached EPA Adwowledgment of Consent.
<br /> 1 cerlify that the waste minimization statement identllied in 40 CFR 262,27(a)(if I am a large quanbly generator or dl am a small uanYi
<br /> } ( I( q ty generator}is true.
<br /> Ge/nerato slOfterafgPrintedlfypedName rF SignalYeR,
<br /> �.r !t Manor Day Year
<br /> _A 16.inlemafional Sfiipments
<br /> ❑import to U.S. ElExport ham,_U.S. Port of entrylexit
<br /> Transporter signature(for exports only): pate Learing U.S.:
<br /> Ce 17.Transporter Acknowledgment of Reveipl of Materials
<br /> LLJ
<br /> Transporter 1 Printed/typed Name Signature
<br /> 0 Month Day Year
<br /> ITransporter2Pdrtedrryped Name Signature r l
<br /> Month Day Year
<br /> r
<br /> 18,Discrepancy
<br /> 1 Be.Discrepancy IndiraHon Space ❑ 9uanGty ❑Type
<br /> ❑Residue ❑Pallial Rejection ❑Fuli Rejecdan
<br /> Manifest Reference Number.
<br /> 18b.Aitemale Facility(or Generator)
<br /> U.S.EPA[D Number
<br /> V
<br /> w FacilitysPhone:
<br /> W 18C.Signature of Allemafe Facility(or Generator)
<br /> Month Day Year
<br /> FHa7adV1as.teR',a
<br /> e Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> 3. 4.
<br /> ity Owner or Operator.Certificationof receipt of hazardous materials oovered by the manifest except as noted inllem 18a
<br /> Signature Month Day Year
<br /> 870 v.1Z 17) Previous edllians are obsolete. r
<br /> EPA Foy GENERATORS INITIAL COPY
<br />
|