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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> Form Approved.QtUIB No.2050-0039 . <br /> UNIFORM HAZARD 1 G r rator ID Number }} 11. 2.Page 1'of 3.Emergency Response Phone 4.Manifest Tracking Numb�`er° Q <br /> GBF <br /> WASTE MANIFEST` ► r' ♦ �:0 V.ir rl ' <br /> 5.Generators Name and MAddress Generato s Site Address(if different than mailing address) ! <br /> allin <br /> 5 do � ��'L r►�n�Eaz�E � Imo Pli C� » RD P� � f 7s3 <br /> Generator's Phone: U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> Sat: Joaquin Filter Recl clirt� (.�LUO[�IQ?751 <br /> U.S..EPA ID Number <br /> 1.Transporter 2 Company Name <br /> i <br /> g d[Q55. U.S.EPA ID Number <br /> S.Designated Factli'�I iln i i�.dtJit v <br /> as ! <br /> 14287 E. X'iatining; Parlier, CA. 93648 <br /> t'_U000102751 <br /> Facility's Phone: i <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(ii any)) No. - Type Ouantlty Wt.Nol. <br /> G <br /> Liquid(Used coil` ii:wel..Oil) -TT 236 <br /> LLI <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions and Additioral Information <br />• �t'�.�rP>'c►tecti.c�� {;'l.oth.i�R - �mvr.genc�'y'1�es�on,�e <br /> NAR ,'1 �1 '�`F1Zt {. Q �."• antact San faaquin Filter Recycling <br /> USCL 01L V'A 1 Y CJL) CAI— <br /> 1,554 8-0240 <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: l hereby declare that the contents of this cconsignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,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. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if i am a large quantity generator)or(b)(if.1 am a smalr quantity generator)is true. <br /> Generatar'sl0ffercedriteeyped oma o f _ Signatur` j. ! Month Day Year <br /> #'` -Z Z <br /> 16.Intemational Shipments - <br /> f ❑Import to U.S.. ❑Export from U:S. Port of entrylexit: <br /> z Date leaving U.S.: <br /> — Transporter signature(for exports onty): - <br /> 17.Transporter Acknowledgment of Receipt of Materials - <br /> F Si'n~ure r-• Month Day Year <br /> � Transporter 1 PrinsedlType Name <br /> g i <br /> O <br /> �A j � I <br /> VY <br /> a] Month Da ear <br /> S'i nature <br /> Day <br /> Z ed Name � 9 <br /> Transporter2 Print yp - , <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indiratidn Space ❑ Quantity ❑Type ❑Residue <br /> El Partial Rejection ❑Full Rejection <br /> i <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> CJ <br /> tai Facilitys Phone: <br /> k LLI 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1., <br /> H141 <br /> 20.Desi sated <br /> ty Facili Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as nded <br /> in Item 18a <br /> 9 P <br /> I' PrintedlTyped Name Signature Month • Day Year <br /> OD <br /> i EPA Form 87M-22(Rev.3.05) Previous editions are obsolete. <br /> nE9103NATEn_FACILITYTO GENERATOR <br />