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• <br />• <br />Form Aooroved. OMB No. 20500039 <br />'please <br />print or type. (Fond oestg ea nor use on aim t icy,u.,q .t —1-1 <br />UNIFORMHAZARDOUS.1' na ID Number 9 <br />? <br />agetof <br />3. gpcy e�po�s hone <br />�u-4�4_y �0 <br />- <br />4. Ms limit Tracking Number <br />JJ K <br />- <br />WASTE MANIFEST ��g ° <br />003336210 <br />Genealots Name entl McYng Address QGd. Generators Site Address (if dlHerentthan mailing address) <br />5. <br />���33�/f v �iG�• 9_S3z,� <br />e ealo sPhone: UID Number <br />&Transp�VISP . "Environmental Services � 9824132.2 <br />7, Transporter 2 Company Name U.S. EPAID NMber <br />a. Designated Facility Name and Site Addres r U.S. EPAID Number <br />6880 Smith Ave. <br />Newark, CA 94560 CAD980887418 <br />510-795-4400 <br />Fad it's Phone: <br />RE. <br />9b, U.S. DOT Desorption (inducting Proper Sh'oping Nam, Floated Class, W Number, <br />10. Canlalnea <br />11. TaW <br />12. Unit <br />13. Wade Codes <br />No. <br />HM <br />and Packing Group (If any)) <br />Quantity <br />WINd. <br />1 <br />^r�Type <br />O <br />`q~ <br />0 xJY/J�G <br />t M <br />130 <br />z <br />W <br />2 <br />f7 <br />3. <br />4. <br />14. Spec/�i InWcgans and Additional Information <br />15, GENERATOIrSlOFFEROR'S CERTIFICATION: I hereby declare that the contents oflhis consignment are fully and accurately descroad some by the proper shipping name, and ars classified, packaged, <br />marked and iebeledlplararded, and am N all respects In pmparcondl0on for bansportaccording to applicable imematioreland national gm emmenW regulations. H exportshipment and I am Ne Primary <br />Exporter, I cerHy Nat the contents of Nis consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I arify that the waste miniio¢alion statement klahlified in 40 CFR 262.27(a)(if l am a large quantity geretalor)or(b)Off a a small quantity generator) is true. <br />GeneatorsMeroes PrimerlRyped Name signal Mon Day Year <br />klkc N " �s 22 /d <br />r <br />F <br />16. International shipments <br />❑ Importb U.S. Ewart from U.S. Por of emrylexik <br />Tanaporer signature (for exports only): Date leaving U.S.: <br />w <br />17, TanspaterAcknaWedgmmtof Rea'ryt ofMaterals <br />Month Day Year <br />oTransporter <br />a <br />l Prtmedr dName Signature <br />l <br />Transporter rnted/Typed Name Signature Monty Dey Yaer <br />r <br />18. Discrepancy <br />IBa. Discrepancy Indication Space ❑ Duanlity ❑Type ❑Residue ❑PaNel RejacWn ❑Full ReJectian <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />Faclilys Phone: <br />W <br />lad. Signature ofAlonnaw Facility (or Generator) <br />Month Day Year <br />6 <br />z <br />m19. <br />Hazardous Waste Report Management Method Codes (I.e., cause for hazardous waste treatment, disposal, and recycling systems) <br />10Z 3. 4. <br />20. Designated Faclity, Ormer, ur Opealor, Certification of mcdpl of hazardous malerals covered by the manifest except as noted in Item 18a <br />Monty Day Year <br />PrnlediTyped Nama Signatu <br />loci, 107rt I to <br />e <br />EPA Fan 870022 (Rev. 3-05) Previous Editions are obsolete. NATED FACILITY TO DESTINATION STATE (IF REQUIRED <br />