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Please Pont or"a,(Form daslgned W use Lm erte(12-pilch) ewdfer.) FormAppreved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1:GerpreWrlD Num6pr - 2.Page i of 3.Emergency Response Krone 4,ManNesl Tgrackkin umber <br /> WASTE MANIFEST 1 .(800 424.9300 118 27259 JJ K <br /> S:Genaeslofs Nameand Ma ftAddrass GeRsmbhSdeAAdamsto mrivenlawnmaiNg address) '. <br /> PICK N PULL#80 <br /> 3927 CLARK OR 392T CLARK OR <br /> STOCKTON OCA 95205 STOCKTON CA 95205 i <br /> Generators Phbne: - <br /> 0.Tesr em er t Company Name U.S.EPAID Nwnber <br /> UR ENTAL SERVICES .AD028277036 <br /> ].Trmwpoder 2 Compeiry Name U.S.EPAID Number <br /> a.Deslgnaled FaaTlyName and SileAddress <br /> U.S.EPA ID Number <br /> DK DIXON <br /> 7300 CHEVRON WAY <br /> CA 95620 <br /> f DIXONXON AT080012602 <br /> ger, 9b,U.S.DOTOascdPWO Ondx"Proper SNpyeg Nemo,Haard Class,ID Number, 18.Codlaheis 11.Told 12.UNI <br /> HM andPaddrg QoupNo. Typ <br /> (dary)) - e Quark YAW 13.Waste Codes <br /> F dNON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL 00i TcccJJ�""'V G 133 <br /> SOLUTIONS) —i —T- <br /> 2 <br /> iL j <br /> 3. <br /> 4. <br /> t <br /> i <br /> I I � <br /> 14.Spetlal Horsing NwWcdonsandAdNBorwt Inlecmadon i <br /> NAERGf► 961:171*PROFILE#9Bi:DKi00i83***EMERGENCY CONTACL-CHEMTREC 1-900424-9300 <br /> ADDITIONAL EPA CODES:9Bi:,NONE*APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:Ihembydedom MN coomms of this consowrienl orafuey and acwmlay dascnbed above by ft proper sWpping nam,aid are classified,pocketed, ' <br /> marked end kabeted1plawded,and are hall respeds h pmpm MKWM far banspmlawadkg 10 a9Pkable kdomatlomlard national gmrernmunml reWagam.If exporlshipnrenl and I am the Pramry <br /> Exporler,l aAYy Uel ft conbenlsof Ods oonsppumrdaonfarm to Uro tam offs alad*d EPAAdumxledgmenl of C"Al. <br /> Ice"tthalUe waste mk inkallonslakmentldeni8ed N 4D CFR 28211(a)(N lam a lage(uultygenemla)or(b)(dl am a small quaAdly genarebr)a Wo. <br /> OanerafWs/OReroys Pnmed7(yped Name SlgnaNre Monty Day ..Year <br /> �' CCgr <br /> IMmarnatbna wWrads <br /> Li haw to U. . ❑Export kom U.S. Porlolentry/cat <br /> Trw4Grlw afgmMa(lor expects ordy): D84 leaving U.S: <br /> 17.TranspMerAatnoal gmanior lerak <br /> Trampo I Name Mont Day YearIV <br /> a I , <br /> IMISPAMOK FMII Name <br /> as <br /> YM <br /> 1�- <br /> } 18.01suepenry :;• <br /> I8a.Dlsmepancy admilan Space ❑ouam ❑Type ❑Resides ❑Partial Rendon ❑Fee"ad. <br /> Menibsl Refs Numbec <br /> 18b.Nkrrwts Faciry(err Aenerebr) U.S.EPAID Number <br /> i <br /> V <br /> u Facdllys Phone: <br /> 18c.Sbnatwed Alternate Facey(orGenere(a) Month Day Year j <br /> N79.Hazardous Waste Re*Marwgamenl MOdW Codes Os.codes br haaardous aaskbeaarlent,dkspoesl,ad regtlhg ayslam) <br /> 1. 2. 3. 4. <br /> ZO.Designehd FanBy Ownerw Operator.Ceredcaticnof of hazardous materials"red by aes merdlust exceptas rated h Ilam 18a <br /> edlfyped Namepr 3"lum Day /Year <br /> fie^ G�SGQ�IU G 'LI 0 <br /> EPA Farm8700-22(Ree 3.05) Previous adillod wee eta. DESIGNATED FAUHfT6 DESTINATION STATE(IF REQUIRED) <br />