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Pleaso print or type.(Form designed for use on elite(12•pitch)typewriter.) FoirnApproved.O),!U No.20500039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2,Page t of 3.EmergencyResponse Phone 4.Manifest TracIdng Number <br /> WASTE MANIFEST C A 1.0 00 0 -1, •1_t)?2 ). fk(Ct A 1•`?4_5300 012413640 JJ K <br /> 5.Ceneralors Name and h!aii:ng Address Generator's SRoAddress tit different than mai-ing address) <br /> J111--Y LIJBE4'.55 <br /> '1110 M.MAIN cZY 1130 14 NIAIM�3'( <br /> MANTECA CA MAMMA tri 950,36 <br /> GeneralorsPhone: 20 ;�^ ('e^r• <br /> 6.Transporter 1 Company Name U.S.EPAID Number <br /> A:=BURY Ef1SJ ti?)Lt:`sENTI Lkf (-:E!3 t;A 0 Q 2 8 J 7 7 t);3 <br /> 7.Tianspetler 2 Company Name U.S.EPA ID Number <br /> 8.Des,'gnated FarSty Name and Sile Address U.S.EPA ID Number <br /> DK OUXOt1 <br /> 7"300 CHEVRON WAY <br /> 0IX0h1 CA 9lb612.0 <br /> Fav=CjsPhone: 1`70 13!M,:••130013 ('A,I 0 3 0 0 12 ti 0 <br /> ga. 9b.U.S.OOT Oescripeen(indudng Proper Sh Wrig Name,Hazard Vass,11)Number, 10.Conla`nets 11.Total 12.Unil 13.Wase Codes <br /> HAI and Packing Grcup(if any)) No. Type Quantity 4vtNol. <br /> 1. <br /> 0 �CM-f�t RA I"AIIA 3DOIP �YAti}t:,1 OMO(01!_Y IBA l R'i D 0 1. T 0 2 dpi <br /> 0 w i <br /> Z 2. - <br /> �. <br /> 3. <br /> JUL . 7 2017 <br /> 4. <br /> ENVIRONMENTAL HE LTH <br /> nEPARTME-NT <br /> 14.Special Hano'ng Instruct:'ons and AddXonal Infamaton 7 7 <br /> NAERG M :901::17:1. ^ 0I <br /> PR 'ILE.N 988.:1)K 100110 :;aEI"df_`r OVX(""Y t�ONTt'CT:C14LMTREC •:3()0_421..,93t)0•+ <br /> ADOV iLNAL t-E 7 1 CODE•`,a:901 :,NONE N APPROPRIAT' ('[:f2.5ONM PROTECTIVE EQUIP MEET <br /> 15. GEN ERATOR'S10FFEROWS CERTIFICAIION!1 hereby dedaie that the omiems of uus ccnsgnr=t are fu't and accurately described above by the proper shipp'ng name,and are classified,packaged, <br /> marked and labe'.edrplacarded,and are in A respects in proper cond.Von for transport according to apjAxaNa internatbnaland nalwat governmental mgula:'ons.Ile)put sh'pment and lam the Primary <br /> Exporter,l certify that the cwtents of Ehs consignment conform to the terms of the attached EPAAc.FrwMedgment of Consent. <br /> 1 certify that the waste m°n!m'aattoo statement identTed in 40 CFR 262.27(a)(if I am a Lugo quan8tygeneralot)or(b)fill am a sma4 quantity generator)is we. <br /> Generates's,'OflerorsPrintodlTypedNam S�natufe / Month Day Year <br /> 9 <br /> Ile <br /> J f .n emaGona Sir!pntents <br /> F- ❑lmpod to U.S. ❑Export from U.S. Port of enbyfexit: <br /> 2S Transporter sfgnatute(for exports only): Das leaving U.S.: <br /> W 17.TranspoderAckwMedgmenlofRece`ptoff.ateMs <br /> b� Transporter i Pr!nledrTyped Name Signatvre / h1onth Day Year <br /> a. <br /> Transporter 2 PrintedfTyped Name SsTnatura Month Day Year <br /> 18.Discrepancy <br /> 18a.Olscrepancy Indtcalion Space ❑ quantity ❑Typo ❑ResiduoEl 1 <br /> Pafial Rejection El Fu'I Re;eciczr <br /> Manifest Reference Number. <br /> 18b.Aitemate Fad6ty,(o(Geneiala) U.S.EPA 10 Number <br /> U <br /> tQ FadblysPhona: <br /> w IkSignature ofA!temateFa0ify(&Generalor) I'Anth Day Year <br /> d <br /> z <br /> 19.Hazar s'Vast R a gement Method Cafes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj <br /> 4. <br /> 20.Des,'goaled Favity hner Operator:Ce • afon of teceplothazaidousAodils wzered by the manifest except as noted V i m <br /> Print ) me SzTnature r <br /> EPA Forn18700.22(Rev.3.05) Previous editions areobso!ete. DESIGNATED FACILITY TO DESTINATION STATE (IF l�EQUIR d) <br />