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Please print ar We.(Frere designed for tae w WHO(12:01ch)typewrilec) Form Approved.OMB No.2050-0039 <br /> UNIFORMHAMRDOUS LGelneralar lD Nanbm 2.Pagelof 3.Emergency Response Phone 4.Manifest Toabill Number <br /> WASTE MANIFEST CAL000269375 1 866-909-2783 008388093 JJ K <br /> 5.Genmatofs Name and Malting Address Genmaloos Silo Address to moment then ma0g address) <br /> Pick H Pull —Stockton 3927 Clark Drive Attn: Doug Grose <br /> 3927 Clark Drive Stadlet—cm, CA 95205 <br /> Stockton, CA 95205 <br /> Generators Panne: <br /> 0.T.Porter 1 Company Name 74n U.S.EPA IO Numb- <br /> 7.Tmnspoalm 2 Company Name U.S.EPAID Number <br /> 0.Deshymle l Foo7iy Name and Sae Address U.S.EPA N Number <br /> IIS Ecology (Bnntty, HV) <br /> High"asy 95, ilmi. S. of Beatty, P_0_ Bax 578 <br /> Beatty, HV 89003 <br /> F rs Phone: 800-239-3993 BVZ330010000 <br /> 9u, 9b.U.S.00TDeselplon(ndudirg PmperEHpplg Name,Haad Clms,IDNumearr taXonw els 11, <br /> HM and Pac4F19Cyaygs(ifany)) Talar l2 Bnil 13.Vh1ts Codes <br /> Na Type Qwntily Wald. <br /> 1.HonCSA IItc Solid (Oily 352 <br /> AbsoroxbAbsorbent,, Debris) <br /> ns <br /> s) � (� 2ya�a p <br /> i <br /> 3. s <br /> 4. <br /> I 1 <br /> 14.Special Handing Instructions and Addgdome hlermatim <br /> 1) 07-012-8300-3305 <br /> Bill to Worldwide; Wear Appropia£e Protective Clothing; EH Responses Worldlaide Recovery <br /> Sys, Inc_ ; '9S ORDER $221982 <br /> 15. GENERATOR'StOFFEROR'S CERTIFICATION:I hereby declare That the mnlnnts of this consignment ale fully and awaat°ydesaibed above by am papershlpping name,aid are classified podaged, <br /> marked and laheledWamnled,and are In ad respects in proper mdilon for transport according W appl able Idamalonet and national govemmenlal regulal nS.I export shipment and I am me Pmmry <br /> EMPaner,I redly that he co mem,of Ibis mwgnmenl mnlorm to has gems of the allachad EPAklommiiedgmeni of Consent. <br /> I really that the waste mlNmbabon statement denuTiad N 40 CFR 20217(a)(if I am a large quantity premise)or(b)(IN am a mall quantity gmmmn0ls true. <br /> GenemmralDAarors Pdni,,Vyped Name Signabue ( Month Day Year <br /> ( � G,i� <br /> 1 hilern eras Shipment <br /> F ❑Imponn US. ❑EzpMhom U.S. Poncfenbyteal: <br /> S_wTransporter signature(for eVom only): Data leaving LS- <br /> or <br /> 17.TonspenerArknontedgmem of Rempl ofembeft <br /> Transporter 'I yped Name Signal Month Day Year <br /> vOoi <br /> 4 v,-el /`� CL!2.-J741d <br /> franspoder2 Pnaedrlyped Name Slgnanue ( Month Day Year <br /> } 10.Discrepancy <br /> 111a.Osaepancy lndicaWn Spam ❑ puanity ❑Type ❑Rmid. ❑Panrs113si.a onisd., <br /> ❑Full Ro' <br /> Manifest Refearce Number. <br /> JWAlternate Fzcllly(azGenamasas)...............—_.._....__...____...._------- __—___U.S.S"Number._._ _. <br /> !.a <br /> sac. FarJ*'s Phone: <br /> w fat Signature of Allsmole Factiy(or Genamlor) MOIM Day Year <br /> a <br /> Z <br /> a—i 19.Hazardous Waste Report Menage nme Method Codes(Is,moss forhwadaus waste heabrmN,disposal,and recycling systems) <br /> p 1. 2 3. 4. <br /> sa <br /> 20.Oosftimmal Faulty I arOpeotor.Camlimlon olremlelofhezazdws materials mvaed byNo reversed mrent as name In sezn Its <br /> PMIed(Typed No 9 Siommus Month Day Year <br /> L/ oa I <br /> EPA Fan 8700-22(RE1.3.05) Pre us editions ale obsolete. DESIGNATED FACILITY TO ESTIMATION STATE(IF REQUIRED) <br />