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Gl..n..n ..,d..f .:. h,nn lCnr,.. rincinnnrt 4nr i ion nn c ifc !1 'hrnawPeiar S Form ADDroved. OMB No. 2211511-0039 <br />y <br />UNIFORM HAZARDOUS_ <br />1. Generator ID Number <br />- (!A o0o0,y i <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />1 0 ON � S�(+S <br />WASTE MANIFEST <br />R <br />5. Generator's Name and Mailing Address Generators Site Address ('d different than mailing address} <br />ORf;:!4rRi, H `' 0"5`� <br />'650 �s.�R NA6A'RTHUR DRIu TRUCK ISHO3 <br />TRACY CA 0,5376 <br />Generators Phone: 2 09 3 3 19 0 <br />6, Transporter 1 Company Name U.S. EPA ID Number r <br />SYSTEMS, INC. <br />_AFET'1-A'1'FFN <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated FacilityName and Site Address U.S. EPA ID Number <br />SAFETY—):L�,Et� SYSTEMS, INC, 000618 <br />172.2 COOPER CREEK ROAD <br />DENTON, TX 76208 <br />TXD077£033'71 <br />Facility's Phone: <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />qg X <br />t.RQ WASTE rLAM TABLE f.1QUIDS, W.O.S. <br />DM <br />P <br />D001 <br />D006 <br />int; I_ <br />C <br />(GASOLINE) <br />� <br />1 ' <br />213 <br />OUTS <br />U141993 Pu 11 (DID ' 0001 1 <br />z <br />w <br />2- <br />C7 <br />3. <br />4. <br />14, Special Handling Instructions and Additional InformationSK TRCKV09283523 <br />J )ER(z#i28 ax <br />11,jJTH D O € SE, SIJE, UENT <br />15. GENERATOR'SfOFFEROR'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 labeledlplaearded, 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. -y <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (q I am a small quantity generator) is true. <br />nature Month Year <br />Giecator's1C3fferor�Printedlryped famSie 9,Y �,. �j � '� <br />� <br />11 <br />.,,.}�"'�"r �i� I } ��i ..,.�-F - •� r. t 1l� I:""`h. ..+.N"__ i + a��� A"' <br />H <br />16. Intemational Shipments ❑ ❑ { <br />Im rt to U.S. Export from U.S. Port of'entrylexit: <br />Z <br />Transporter signature (for exports only): Date Leaving U.S <br />W <br />W. Transporter Acknowledgment of Receipt of Materials <br />Trantiporter 1 Prin edl7yped Name Sig azure {� ,° ? Month Day Year <br />I <br />'. <br />Z <br />Transporter 2 PrintedrlypedjName Signature f'"'�' C.A., " 'k.,, Month Day Yeti <br />nc <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />187ltemate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />Facility's Phone: <br />w <br />18c. Signature of Alternate FaciI4 (or Generator) <br />Month Day Year <br />H <br />Q, <br />Z <br />C7 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />2, 3. <br />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 />PrntedlTyped Name Signature Month Day Year <br />EP. pip 7 U (Rev, 3-05) Previous editions are obsolete. uttt A t urs a rrvt i l %lur 7 <br />3 ytU.}'rc' 2 rv5) <br />