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-I <br /> Please nt ar ( Ig ( -p )typ ) <br /> pd type. Form des nedfa useen elite 12 Itch ewdler. Form Approved.OMB No.20504M <br /> UNIFORM HA2ARDOU31.GeneaarlD Number 2.Pa e I of 3.Em en qResprose Plwn4.MaN1l Tracdng Number t <br /> -- - I <br /> WASTE MANIFEST 000269 75 1 (900)4248300.._ 011827261 JJK <br /> S.Generabrs Name and Mai Address - <br /> �9 Genemkrs Sb Address(8di6erenl than mailing address) <br /> PICK N PULL#90 <br /> =7 CLARK DR 3927 CLARK DR <br /> STOCKTON CA 95205 STOCKTON CA 95205 <br /> Generebra Pharos: 916(3:99-2000 <br /> 6.Transponer 1 Company Nacre U.S.EPAID Number <br /> N E ALS SERVICES AO028277036 <br /> T.Transporter 2 CompanyName US.EPAID Number <br /> 8.Designated Fad ity Name and Site Address U.S.EPA ID Number <br /> DK DIXON j <br /> 7300CHEVRON `MAY 1 <br /> DIXON CA 95620 <br /> Fees sPhona: f70 AT080012602 <br /> go, 9b.U.S.DOT Descripran(IndMag Proper Slipping Name,Hazard Class,10 Number, 10.CoMaMn 11.11,110 I2.IbuTi <br /> NM and Packig Gratpplarry)) No. Typo pwnk WlAW. 13.Wari Carrie <br /> NDN-2CRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL 001 T 0 133 <br /> SOLUTIONS) <br /> �a4{ <br /> W 2. <br /> i <br /> 3. I <br /> I <br /> 4. <br /> 14.Spedal Handbag Instructions andpddbonxi Information <br /> NAERG# 9131:171*PROFILE#961:DK100183**"EMERGENCY:CONTACT:CHEMTREC 18004249300 <br /> ADDITIONAL EPA CODES:9Bi:,NONE*APPROPRIATE E AL PROTECTIVE EQUIPMENT <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION:thembydWatethat Drecontenlso consignmenlam MyandaccurabydascnbedahovebythepropersNpphg rmme,axd archseW,packaged, I <br /> marked and bbeledlp(acarded,and are ha8respecrinpropercarditbn furtuanspataccordutg loapokable lnbrnadonalendnatlonalgovemm talmgula0om.IlexponsNpmenland lemhe Prcnary <br /> Exporter, ceNy Ualthe contentsofWs conslgnmenlconformto Ne reamstitheaaeched EPAAcWtowiedgmenlofConsent. <br /> I terrify that the waste min nutation slalemenildrumfed In 40 CFR 262.27(a)(d I ama large queerly generator)a(b)pfl area small quan9ry9enemla)is We, j <br /> GeneralWslo1�fferors Pnnledrryped^Name + / Slgnew ' / Month Year <br /> hot yU L� V ✓I V <br /> —s 16.Imematlmal Shipments <br /> Z <br /> 111 to U.S. ❑Expwtfrocir Pat ofanty7 . f <br /> Transporter signalae(IDI exports only; Dab(raving U.S.: <br /> 17.Taenspona dgmentof"t of <br /> gTM 4p. yped Name Sigrubee Month Dry Yar. <br /> N <br /> Franalpf remlaWlyped Name Slgnalure <br /> Lu L i <br /> t18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Omamw ❑Type ❑Resume ❑PatOel Releddon ❑FW Re)ulbn <br /> Mantfesi Reference Number. <br /> 16b.Allomme Facgy(or Generator) US.EPA NkmOer j <br /> � I <br /> U j <br /> tors. fadlys Phose: <br /> 4� 16c.Signature of Alternate FecSdy(or Generator) Month Day Veer j 1 <br /> Y <br /> i <br /> y19.Hazaduus Waste Renal Management McWod Coda(ke,codes lorhazardous wastefraMml,disposal,and ruycingsystems) <br /> o i. 2 3. 4. I 1 <br /> 20.Desigreted Facialy,Ownce aOpemior.Caddcatbnofffir:041hezadous materials covered bythe maNWI except asnded N Ilam l8s <br /> Pan Name Sgnaare 4 Month Cay Year <br /> hr 10 <br /> EPA form8704221Rev.&0.5) revlouswitionswe obsolete. DES GNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />