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Pleasepont orty a.(Form designed for use on elite t2- itch l wiiter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator in Number 2.Paget OFF,.Emergency Response Phone .Manifest Tracking Number <br /> WASTE MANIFEST C"p?,C1Gaa'143$93 '1 QF.) e)e'tlt-gam) iJ05772" 85. ' FLE <br /> 5. eneratora Via=and Mailing Address Genemlors Sire Address i different than manual addr ) <br /> .rx, ore arra 5&I i9�atT68154 <br /> fp�.C). SDx It77 G 2500 W LOW Ave. <br /> Grinw11iors hone:tlt' IirlTarDar;ta, 1;,4 r12881s SkiE1)dL'i7-57f)0 1_4Tt11t; C; 135 ? <br /> .Transfamel any Nam U.S.EPAID Number I <br /> 7.Transporter Company Name U.S.EPAID Number <br /> I <br /> B.Designated Facility Name and iteAddreu U.S.EPAID Number <br /> US Ewlof4y, Nwada Ofrers#(Drs <br /> Iltfjilevmta P5, 12 miles S. of 90ml r. <br /> l tdVT3:,1JJluaari <br /> Fa Pibnb: " <br /> (77 <br /> 6) 50,9204 • <br /> 911, 9b.U.S.DOT Desorption fmcktdng Proper Shipping Name,Hazard Class,10 Number, 10.ew ahem 11.Total 12.UNt <br /> HM end Paddng Group(rfeny)) No. Type Quantal WWo1. 13.Waste Codes <br /> 1. <br /> o � l:tl3175, SDlids, t;nrrtainlny FlarnrnaPile Liquid, n.0.5.,11.1 362 <br /> 4 FG II (t'On#ain5 Gi+raylina) '' p <br /> Z 2. 1DtA moi``. <br /> I <br /> 3. SRI L ,Cr V E D <br /> Apg 1 6 2013 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> 14.Specht Handling lnabu;tiore and Lfr <br /> E icor k' 133 4h`f`AR ALL APPRC)PRIATE BL.SU` 0,3123T <br /> 1181130 rr;7J: <br /> PRC)Tl<rTiVF CLOTHING. csla;isa I <br /> PR( "ILE'N L57-a1d iS f <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION:[hembydodare that the conlwls ofthls consignment aro My and scaretey dosorbed above by the proper shlpping name,and are dasslfied,packaged, <br /> marked and labeladnplacorded,and are W all respects in propermndition for transport according to applicable Inlema8onal and national governmental regulations.If export shipmrdand I am Bre Pdmary <br /> Exporter,I oerfilythat the cements of Us cors cont eonfotm to the farm of me attached EPAAckroMelgmenl of Consent <br /> I ce"that the mate minimization statement identified in 40 CFR 262.27(a)pf I am a large quangygenemtm)or(b)(d I am a small quangtygeperafor)is rue. <br /> GeneratoralOfferoes Anon ype7 e Ingnawfe / y yffir <br /> Larvy F,.'iuntha,d of EIESI On behalf of qifierator <br /> 15.International Shipments <br /> ❑Import fo U.S. ❑Export from U.S. Pon of emrym* <br /> Transporter stgnalm for exports only); Date lea ' U.S.: <br /> 17.Trensp ilerAcknowledgment of Recelpt of Ma twbls <br /> mnsporter 1 Pnmedrryped Name Signature ,on y ear <br /> ye It It yet—t., 14n L <br /> Tmnspofcr2Pr I"7yped Name pna a tonin Day ear <br /> 19.Discrepancy <br /> 16a.DiscrepaneylndcaeonSpace ❑ cmamty ❑Type ❑Readw <br /> ❑Pan9al Relaceon El Full Rejection <br /> Manifest Reference Number. <br /> 18b.Altername Facility(or Gewralor) U.S.EPA ID Number <br /> U i <br /> LL 18, s Phone: <br /> w 18c.Signatwe ofNiernale Facility(or Generator) Month Day Year <br /> 6 <br /> y19.Hazardous Waste Report Management Method Codes(Le.,codes or hazardous emsre treatment,deposal,and Ngdvg systems) <br /> c1. ,..y._�,.. 2. 9. 4 <br /> 20.Desgnated Fadey erorOpemtw..Cerdw5mofrecatptolhazardwsmalerals vered by ma maNfesl except snot 1n Item 1811 n <br /> PdnledrF N e nature N m y Year <br /> � . _ J I <br /> 1700-22(Rv.31C5) Pmvicuse (tionlard oI1e . .v ` IGNATEDFACILI YTOGENE ATOR <br /> a�i54 <br /> �o3'�5U <br />