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Please print or type.IFofifid sgned for use on elite(12-1 typewriter) Form Approved.OMB No,2050--003 <br /> UNIFORM 1.Ge 1-211 of k3.EJW)RVy!JSr8 4.Manifest Trackling Number <br /> 0 tj 0 <br /> WASTE MANIFEST"! I rmzlr'�'�,m ;7 14057643 JJK <br /> erall SitaAddress If different than mailing address) <br /> =2 S SINCLAIR AVE <br /> STOCKTON CA li <br /> 209.774-61=11 <br /> Generators Phone; .1 7. , , 1 7 1: <br /> 6.TraroaptiZMNPAMONMENTAL SERMES U.S.EP61WV* <br /> t If 2-1 7036 <br /> 7.Trounsponei-2 Company Name U.S.EI <br /> 6.Design fto U.S.EPAPINumber <br /> 26,6, 1 <br /> Cs.MPTON CA 944222 <br /> FacIls pfore; (aili I <br /> ge. 9b.U.S.DOT Desaiption(Including Proper Shipping Name,Hi Class,ID Number Containers if.Total 12.Unk 13.Wade Codes <br /> Y HM end PackingGroup il A,. No. "Tyl Quantity wtivol. <br /> 1, 13Z. <br /> SOLUTIONS) <br /> 3 <br /> 4. <br /> 14.8p.odal He"ni Imiructons and Additional Information <br /> EMERGENCY CONTACT CHEMTHE-i 9@3:171 P901"ILE#91b.' 3W541 0"HYLENE GLYCOL <br /> SOLUTIONS *APPROPRIATE PERSOtW-PROTECTIVE EQUIP" T <br /> 15., GENERAT R'SPOIFFEROKSCtRTIFICATIOW I hereby declare that the contents of this wm*nnni are(I and accurately described above by the proper shil name,and are classified,packaged, <br /> "marked end Isibelediplacarded,and are In all respects In proper coral fortransport a=rdlng to applicable international and mulaorral governmental regulations.If export shipment and I am the primary <br /> Exporter,I certify that the contents of this consignment conform to the arms of to attached EPAAcknowledgment of Consent <br /> I certily that the waski mitimIzi statement ldentliled In 40 Cl 261 Of I am a large quantity generator)or Il(IFI am a small quantity generator)Is true. <br /> Generalor'sU01femor's PrIntel/Typed Namesignature MOW Day Year <br /> 6"ki Jay la A <br /> 16.InteMatlonal Shipments El Import to U.S. ❑Export from U S. Pori of entrylexii <br /> Tnensporter signature(for exports only): Data leaving I <br /> IX 17.Transportarfickoxxidedgment of Receipt of I <br /> Signature Month Day Ym <br /> 0 <br /> 1 <br /> Trarsporler2 Prontedryped Name at, 2 4Y Year <br /> of <br /> 18:Discrepancy <br /> the.Discrepancy Indication Spam Quari El Partial Rejection El Full Rejection <br /> "PECENTz a iestRefermne Number. <br /> 181c.Afternate Fatality(orGomrsdi U.S.EPA ID Number <br /> =A G2, 2011, <br /> ZE <br /> 0PW"fUIl FFEIITH <br /> 18c�Signature of Alternate Facill(or Generator) Month Day year <br /> P E f'�F'J I T/S E 7'�!�E!" <br /> ti <br /> ti <br /> 19.Hazardous Waste Rappon Vanagaonaam Method Codes(I.S.,codes for hazardous waste treatment,CIRSirms,and Miri systems) <br /> 2. 3. 4. <br /> Certfficationof recall of hazardous materies covered by the nentestexcaptas noted in Item Ise <br /> PITImped Name in Day year: <br /> ;lip vb <br /> EP qrm87.OD-22(Fei fPrevious edilitmoref,obsoleleDESIGNATED FAZILITYTO GENERATOR STATE(IF REQUIRED) <br />