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Please pnnt or type.(Fctrrn deslgnod for use on able(12-pitch)typerwrtter.) Form Approved ONB Na.205fb0Q38 <br /> 01F©RM FIAZARDOUS 1.Generator ED Nuinbee 2 Paget of600) <br /> Emergency Respm%a Phane 4. fyC u� <br /> WASTE MANIFEST C R L 0 0 0 3 1 9 5 3 2 ; 424-930 4/''@ 34 JA <br /> 5-GenwR&s Nerme and Maung Address GaneraWe$Site Addraas(if de![menl limn mahn9 address) <br /> 11ACO TRUCK STOP <br /> P 0. wx8wco ROOTAGE RD CA <br /> RIPON CA em <br /> GDneratoes Phone: 29LM2112 <br /> 6 Transporter 1 Company Name US EPA ID Number <br /> RY EWRM*NTAL SERVICB C AD 0 2 H 2 7 7 0 3 S <br /> T Transporter 2 Company Name U 5,EPA Number <br /> a Desgnabd Facility Name and SBaAdd'ess U.S.EPA ID Number <br /> DEMENM 1 KERDOIDN <br /> 2=IORTH ALANEC3A STREET <br /> Fadit'sCOWTON 010111537-MCA CAT 0 0 0 0 1 3 3 `0 2 <br /> 9a. 9b U 8.DOT Descripuuri(including Proper Shipping tone.Hazard Cbass.IP Number, 10 Conga aura 11.TOW 12 urit <br /> 11 wraste Codes <br /> HM and Packng Group(f1 any)) No Type Qua" Wt voL <br /> � t <br /> NOW-RCRA KVAROOM WASTE,UQUD PLY WATER) DM <br /> Z 2 <br /> ul <br /> 3- <br /> 4 <br /> 14 Special Hand)atg Irmtruchons andAdditianal fnformatioa <br /> NAER00 MI : 171"PROFILE 0981 .MOB APPROPRIATE PERSOWL PROTEDTIVE ECUPMENT <br /> 15 GENERATORWOFFEROR'S CERTIFICATION: 1 herebydedam that ifs oontants of this consgnment eau filly and amlMly described above by ft proper s4#rg name,and are classified.Packaged, <br /> masked and fabefed`placarded,and are in all respects In proper condition for Uanspod according to applicable intematmnal and national goverrmenfai reguta6ans.If expDd shipmerd and I em the Primary <br /> Exportef,I ce"that the contetds of he caWmwn wltlann to the terms of ede atlaeW EPAAduwwledgmanl of Consent <br /> I wrtrfy that the waste minimization atatamont rdontifi#J in 40 CFR 262.271a)[f f am a large quantity generator)or(b)(d 1 am a smell quantity gernrebr)is We <br /> eraaro?s Printe�dfl+�'yped me S' azure Month Day Your <br /> J <br /> A.� 0 import bo U.S Q ExpDrtfrom U.S Portof anlryr'exit: <br /> '�— Thuisportar s gnabxe(for&Nxnts only) Date feavi S- <br /> i I <br /> ..17 Transporter Acknoyledgm d of Receipt of Materials <br /> Transporter 1 PraNedfT 5iyna Month Day Y ar <br /> Q Transporter 2 Prints ype me Month Day Year <br /> 16 Discrepancy ^ ��yy <br /> lea.Dxxrepa-°wy Indication Space �cluanlily O Typo ❑Residua M Partial Rot, L_1 Full Rejec#ori <br /> Mariftm Refewca Number <br /> 18b.Al emate facility(or Cgner ft) U.S.EPA ID N=ber <br /> cs <br /> rat Fociwo Phone: <br /> w Ilk.Signature of Allemate Feciity(or Generator) D �Y ew <br /> d <br /> a <br /> 19.Hazardous Waste Report Managemmrit Method Codes(l.e,codes forhacardous waste treatmem.disposal,and recyding systems) <br /> 3 4 <br /> 20 Designated Facility Ownrr or Operator CmtlffcaSon of rewips ul hazardous materials covered by 1he r wnifeat except as nded in Item 19a <br /> Pnnfodrryped Name Signehrs AWh Day Year <br /> EPA Foam 8100-22(Rev 3-)5) Previous edtttons are obsdete. DESIGNATED FACILITY TO GENERATOR STATE TIF REQUIRED) <br />