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0 <br />Please print or type. (Form designed for use on elite 112 -pitch) tvnewritar t <br />DESIGNATED FAflILITYTO DESTINATION STATE (IF REQUIRED) <br />- -1 norm Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS 1 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone Trac Iner <br />WASTE MANIFEST CAL000269315 1 877-737-527700940395 ��K <br />5. Generator's Name and Mailing Address Generators Site Address (d di farent thanPick B Pull —Stockton <br />7addram) <br />3927 Clark DriveGrose3927 Clark Drive <br />Stockton CA 9520 <br />Stockton, CA 95205 r <br />Canards Phone: O1F 1 —a OF. <br />S. Transporter 1 Company Name <br />U.S. EPA ID Number <br />Worldwide RecoverT S stns Inc. <br />7. Transporter 2 Company Name 7lr <br />U.S. EPA ID NumbeGA'2nnO1 <br />8. Designated Fw)4 Name and Site Address <br />U.S. EPA ID Number <br />DS Ecology (Beatty, NV) <br />Highway 95, ilei. S. of DeattY, P.O.. Dow 578 <br />DeattY, IN 89003 <br />Face sPh": 800-239-3943 <br />98, <br />96. U.S. DOT Desoiptlon (including Proper Six" Name, Harare Class, ID Number, <br />1 100, Coma <br />Containers <br />HM <br />and i"XIO g Group (darty)) <br />11. Total <br />Quantity <br />12. Unit <br />W. UnitV01 <br />13. Waste Codes <br />Type <br />1 Ycn-RCR2t Hazardous taste Solid (Oily <br />o <br />Absorbent, Debris) <br />m <br />D <br />352 <br />2 <br />2. <br />W <br />l'J <br />3, <br />4. <br />14. Spatial Handling instructions and Additlonal Information <br />1) 07-012-8300-3305 <br />Dill to Worldwide; tear Appropiate Protective Clothing; EY Respolnsa# Worldwide Recover=,. <br />— <br />SYS, Inc• ; WE ORDER #232420 -JS ,. .. <br />is avis l! li fu 117-1. agora esrnbea da,nn, by me Proper snapping name, and are Classified. packaged, <br />marked and lebeedlplararded, and min all respects in proper coing ndl for transport al,,mto applicable imemabonal and natonal govammentaI reguWfions. If <br />eyoed ski meant and I am me Pn <br />Exporter, I ce* ma me contentsof this oatslgmnent =f= to MO temu of the attached EPAA6mx medgment of Consent ` p ° <br />I terrify that me waste mkemvetlon statement identified in 40 CFR 26127(a) (if t am a large quantity gerserator) or (b) (d I am a small quantity generator) is true. <br />Ger affe ORerde l'dnted/Typed NemoSgnature ohm DdY Year <br />F <br />16.I mationalS Nrnents <br />❑ Irl to U.S. ❑ Expod <br />z <br />U.S. Part of entry/exit <br />T nsplxme signalling fore <br />( �e °0N)' <br />Date leaving U.S.: <br />17. TransporterAcfr�odedgment of R 'pt of Me <br />Transporter 1 PrintedRypetl Name p1g re <br />a <br />Mon Da Year <br />W <br />2 <br />Tanspwtw2PrmwvTyyed Name <br />Monro Day Year <br />} <br />18. Discrepancy <br />18a. Discrepancy mication Space ❑Duentily, ❑Type ❑Residue ❑Partial Rejacbon ❑Full Reaction <br />18b. Aflemaa Fatillq (ur Generator) Manifest Reference Number <br />.� <br />U.S. EPA ID Number <br />U <br />LL <br />Farilitys Phone: <br />w5Dffiq�lsd <br />a ofAllnnae Fadley (ar G ex., <br />Q <br />Month Day Year <br />Z <br />Ww <br />Waste Report Management Method Codes (i.e., codes M harerdous waste lrea in en( disposal, a'd acyding sysball <br />�32.34. <br />Faokry Omar or Operator Certs aeon of receipt of hazardous prawn is covered by da manifest exceptae need in Item 188 <br />d N <br />7 SignaWre <br />`�'�['''/1 ' <br />EPA Form 870022 (Rev. 3-05) Previous are ohwntn <br />DESIGNATED FAflILITYTO DESTINATION STATE (IF REQUIRED) <br />