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0 • <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,GeneralICAL000269377age 1 of 3.Emergency Response Phone Manifest Tracking Number �+ <br /> WASTE MANIFEST 1 -,,7-43,8T 4. o s" G B F <br /> 5.Generator' n*Atq"t ,dire _ Generator's Site Address(if different than mailing address) <br /> 3927 CLARK i)RIVE <br /> STOCKTON. CA 952054M1 <br /> Generator's Phone: 2209-46 2[1927 <br /> 6.Transportetftfp�gyi cling mice Inc U.S. PAfO 80000I 9761 <br /> 7.Transporter 2 Company Name U.S.EPA ID Numberjj <br /> B.Desi nater�F 1ity[lame and ite Ad ss U.S.EPA ID WR0 0`0 i97v e <br /> g (��1 HlOyCl€!!>q��TVECe Inc (i�Ui17� �t).� �'� <br /> 101 H;Rgen ili <br /> Woodville, VVI 54028 SIXI-2.49-2WA <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No, Type Quantity Wt.N'o1. 13.Waste Codes <br /> 1. <br /> 4 Non-RCRA Hazardous Waste Solid � �J <br /> Lu 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special i Instpictiapps andAdditioaaf Infpjntaf�ion ` <br /> trsf T>a[e Ve 410LfM and 47ewrear. 9.1 - OILY ABSORBENT E.R.Q.-9.4 #171 <br /> ��}( +7 ,:!t.t G' U 4 G ! One or►none of the rnater'lal�{isted on INS.Mi malt <br /> �} -}� be YCfe�as,,al�ematILAIll ltty (ADC),orodw <br /> l I�/TT 5 f� rnetlio�w`iifc ti ups the-wia ertal n pr on the land. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratoeslOfferors Printedlfgped Name qn re Month Day Year <br /> -� Q <br /> 6.Intematio al Shipmants <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Hale leaving U.S.: <br /> LM 17.Tr nsporter Admowiedgment of Receipt of Materials 1 <br /> Tran otter nne yp Name Sign ture Month Day Year <br /> CyU) }` f- M C�t ill Y <br /> Q Tra sporter 2 Printedayod Name Signature r" 'Month Day Year <br /> t- <br /> 18.Discrepancy l�I <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ElPartial Rejection ❑Full Rejection <br /> Manifest Reference Number, <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> rn19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Q 1. 2. 3. 4. <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Print Nam � i Si nature Da <br /> �r -, = 15 <br /> EPA Form 22 Previous iditions are obsolete. <br /> DESIGNATED FACILITY TO GENERATOR <br />