Laserfiche WebLink
Please print or type.(Form designed for use an 0016(12-01oh)typewriter.) Form Approved.0148 No.2050.0038 <br /> UNIFORM HAZARDOUS Z.Pagelol 3.Emergency Respome Phone A.Mural Tracking Number <br /> WASTE MANIFEST c1.GaMreNfb Number <br /> A L 0 0 0 2 6 9 3 7 5 f8001424.9300 > 011827254 J J K , <br /> 6.Gemmtark NareeMMe6g Addles Ganamtoys S&Address(If different Man mgft address) <br /> PICK N PULL#80 <br /> 2927 CLARK OR 3.927 CLARK DR <br /> STOCKTON CA 95205 STOCKTON CA 95205 <br /> Oemrebys Posom: 91 a - <br /> 6.Transporter tComparryNan U.S.EPA IO Number <br /> MENTAL SERVICES 0 0 6 <br /> 7.Tmnspader 1 Canparry Name U.S.EPAID Number <br /> B.Oeeigmled FxRlyNam eMSReAWresa - U.S.EPAID Number . <br /> DK DIXON <br /> 7300 CHEVRON WAY <br /> DIXON 6 CA 95620 A T 0 820 012 6 0 2 <br /> ger, 9b.U.S.00TDeaaipfion(Nddig PrapaSNppNg Name,Hazard Class,ID Nunber, 10.CantaNers ii.Tdlal 12 Un1 <br /> HM adP-Mng Gr-P(tlaM) Na Type Quantity WOM 13.WasleCades <br /> I <br /> Is: INON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/MIXED OIL) 0 0 i T f G 221 <br /> erg (F <br /> w 2 <br /> � I <br /> 1 <br /> 4. <br /> 14.Spacial Handfeg lnstntl andAdODW Information - <br /> NAERG# 961:171*PROFILE#9131:DK100164 EMERGENCY CONTACT_CHEMTREC 1-800.424-9300 <br /> ADDITIONAL EI'A CODES:981:,NONE*APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> /6 <br /> 16. GENERATOR'SIOFFEROR'SCERTIFICATION:I hereby declare[mum antenlsafthb ampnmenaebuty and aaaelely described some by the proper shipping name,and aredassfiied,packaged,'.. <br /> marked and Whele0aarded,and we In al respects In limper condNon for transport woordmg to app&able Worm8omlend naBaW goseranenW regubdare.Ife)W shpmard ad l am Ne Primary <br /> Eaparlar.l adyy Nal Ne conientsof gtls co ndgma N conform to Rn terve nihe eeached EPAAd=W&dgmen oICamem <br /> I avtify Na Na Marb ndsimlta@on alslementldentfad In 40CFR262271a)(d lanahryaquantllyganeah)or(b)(dl ama M i <br /> cmmeratoes"emrs PdMedrlyped N r Signxhxe Monk Day - Yi <br /> 16. NmaBoml SNpmen@ ❑ envylael - <br /> 0.—s ❑impartb U.S. _ Exgodfr .S. Pad of ; <br /> Z <br /> Transporter signature(lar exports oriy): - Date le8*9U.S.: • j <br /> 17.TmupofA&mwledgmerloffla oolMa6-�b � <br /> rx T 1 Pdn"Typed Nate S*Rturs Wath Day Yes <br /> a/ <br /> Transporter 2 Printedflyped Nam Sgnatum Monty Day Yee <br /> Is,DbtteP@ny <br /> lea[eHtlepauq.N`daeon Space ❑Qrunmy []Type ❑Raeteue ❑P.UR*clbn ❑Rd Relecdan - <br /> Manifea Reference NarNr. <br /> 18b.Altemale Fadity(aGenemtw) U.S.EPA ID Number <br /> U <br /> LL FadHys Phone: <br /> Q 180.Sigmturs of Alternate FacRy(aGerers" MarRr Day Yea <br /> T <br /> C) <br /> 19.Hazardous Waste Report Management Me sur Codes(La..codes fa harardwswasle treahmn,dlspasal,and recycling systema) <br /> a 1. 2. <br /> 20.Designated Fatty QmeraOpemter.CatiBwtlanWmceiptafhawdoua malarias MOW by Ne Nfadexcept a noted N Rem tea <br /> PMtediTyped New Ngrlom Monk Dry Year <br /> "CAo- 61 l 30 7 <br /> EPAFmm87W22(Rev..3-05) Previous editlomea obsoete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />