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- - ti-4 <br /> J Form Approved.OMB No.20517=0039 <br /> Please print or type.(Farm designed for use on elite(12-pitch)typewnter.) <br /> _ <br /> UNIFORM H 4ZARd0US 1 Generator ID Number 2.Page t of _3.Emergency Response Phone 4.Man'rfest Tracking Number <br /> WASTE MANIFESTd+ =5v "0"0 0-0 6�12 2 71 . <br /> G B F <br /> 'i� 5 r�S f <br /> '5.Gerteratoes Name and Mailing Address Generato s r di_.E _ n mailing address) <br /> I <br /> A Unified ' stern` roc ifs'" U�11F 3 i 1 �� k-,t-{ Cis 0�C, 5. <br /> 5"�00 Sheila`Street Commerce Ca. 90040 ��=1� � l°`'t1`C 0L L VF.), V'.C}:P,c.A,&C-11 IS <br /> 1:3231 26#-52v> s 1+�1K%t , � me* - (,Toc <br /> Generator's Phone' <br /> 6.Transporter 1 company Name U.S.EPA ID Number <br /> oaquin Filt'r Recycling . 001€j2751" <br /> 7.Transporiar.2 Company Name U.S.EPA ID Number i <br /> 81 Designated Fadlit)�I�r>k��td Site Adt4S U.S.EPA lD Number <br /> 14287 E: +"iannuig,"Farliear, CA..9364E . - <br /> ,;'c5aj i94-024C, CAL000102751 <br /> Facility's Phone: <br /> ga 9b.U.S.DuT Description(including Proper Shipping Name,Hazard Class,ID Num_ ber, 10.Containers .11.Total= 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 7 ON RCRA Hazardous Waste, X21 <br /> a J�iquid jised OiU=Xtiied Oily .. -. .. .. 1.... .._ IT ..' <br /> LU 2. <br /> LLI <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> .• CF <br /> % r Pot� vz Clothing Emerericy Respos r <br /> contact— 'San Joaquin Filter Rec1clit g <br /> i559) 49$-42� <br /> 15. GENERATORWOFFEROR'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 iabeledlplacarded,and are in all respells 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 Ackn6wledgment of Consent. -; <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(it I am a all quantity generator)is true. ' <br /> Generator sl t s Print !Typed Name Signature. Month Day Year <br /> �6 . LIL/ 1tor <br /> I <br /> .,..r 16.International Shipments; _ Ex ort irorrsU.S. Port of entrylexit: <br /> F• �-'. ❑Import to U.S. ❑. P <br /> Trans'porlar signature{for exports only): Date leaving U.S.:' <br /> LW 17.Transporter AcknoWedgrilent of Receipt of Materials <br /> Transporter 1 PrintedfTyped Name Signature Month Day- ,.Year <br /> a <br /> sn ;: Ponth Day Year <br /> za Transporter2 Print yped Name Signature <br /> r <br /> 18.Discrepancy "M <br /> w El Re'ecdon, <br /> 18a.Discrepancy Indication Space ❑Type ❑Residue'• <br /> Partial Rejecti6n I <br /> ❑ Quantity <br /> Manifest Reference Number. <br /> 18b.AltemateFacility(or.Generator). U.S.EPA ID Number <br /> Facility s Phone: s <br /> B 18c.Signature of Altemate Faclity(or Generator) Month Day .Year <br /> Z <br /> 19.Hazardous Wast anagement Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyrJing systems) <br /> 1 2. 3. 4. . T <br /> 120.Designate Fadllty Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as notadjo Item 18a/' <br /> Printed/Typed Name Signature Month Day .Year <br /> EPA P870O.-4(Rev.3-05) Previous editions are obsolete. <br /> OF91(%NATF0 FSCILITf TO GENERATOR- <br />