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• <br />.Blease print or type: f,F01M designed for use on elite <br />UNIFORM HAZ4kDOUS 1• Generator ID Numl <br />WASTE MANIFEST -101 <br />5. Generator's Name and Mailing Address <br />FS'YSTEM TRAN8PORT, crwT? <br />707 E. ROTH RD, <br />FRENCH CAMP, CA 05321 <br />Generators Phone: <br />6. Transporter 1 Company Name <br />SHOP HANDS SOLUTIONS <br />7. Transporter 2 Company Name <br />1 of 3. Emergency Response Phone <br />then <br />Farm Approved. OMB No. 2050-0039 <br />tracking Number <br />1421261 JJK <br />I <br />,I <br />U.S. EPA JD Number <br />U.S. EPA ID Number <br />' <br />;'S��f►+�hAN(Cp? JS�`Addra8.QeB <br />DOVALLr <br />I <br />U.S_ EPA Il Number <br />. <br />111355 Mi TE ROCK RO., <br />FiANl,HO CORf�tlO:,,e' <br />CA1�Ea808049 <br />FacilltyaPhone; <br />ga. <br />HM <br />9b. U.S. DOT 7 <br />and <br />lnefc <br />11. Tote) <br />12-unitQ� <br />13 Codes <br />Type <br />Quantity <br />WtNol; <br />-Waste <br />CA: <br />E]hA <br />9501 <br />P <br />23 <br />352 <br />z <br />ua <br />2. <br />C9 <br />3. <br />i <br />. E19rator a,,3 <br />4. <br />14. Special Handling Instructions and A. I formation <br />PRORLE#R-1 x`577 <br />APPROPRIATE PROTECTIVE CLOTHING <br />� <br />SEF ERG #171 <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ariil ere classified, packaged, <br />marked and labeiadlplecarded, and are In all respects In proper condition for transport according to applicable international and national govemmentaf r8gule6Dn9. tfexport shipm�nt and I am the Primary <br />Exporter, Ice* that the contents of this consignment conform to the terms of the attached EPA Acknowledg <br />t of Conant <br />I carlify that the waste minfrtd�ffon statement Identified In 40 CFR 262.27(x) (If I em a large quanttty ganem r) <br />(b) (IN errr a small quantity gene W mre. <br />Ge s!{)P rpr a Pian Asim sigiiaturI <br />9j <br />Month —ay,—Y- <br />q./ . I . <br />_% <br />o <br />0..� <br />16. <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from US, <br />Port of anhyrexlE <br />Transporter signature (for exports only): <br />Date leaving U.S.: <br />17. TranaporterAcknowiedgmant of Receipt of Materials <br />OTransporter rinted/Typed Name Sf nature <br />v' /%� g <br />� o <br />19. Discrepancy ED165, Diacrepanty Indication Space Quantity ❑ Type U Residuc <br />Manifest Raferenae <br />18b. Alternate Fac€llty (or Generator) <br />u¢. Fac ility'a Phone: <br />I lic. Signature of A temata Facility (or Generator) <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />61. 2. 3 <br />20. DaElgnated Fac4ity, Owner or Operator. Certification of receipt of haardoui mateflals covered by the mans st exce t s noted in Item <br />Pi edfTyp come Sign <br />EPA form 9700-22 (Rev. 3 05) Previous editions are obsolete, <br />600 Z <br />I Partial Relacdon <br />U.S. EPA b Numbe <br />4, <br />DESIGNATED <br />LI Full Rejection <br />rYTO GENERATOR <br />917:00 9TOZ/6T/170 <br />