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~, � designed w -- - <br /> Please print or type.(Form for use on elite(12 pitch)typewnterJ' Form Approved.OMB No.2DSO-OD39 <br /> UNIFORM HAZARDOUS 1.Generator IDNumber 2.Page 1 of 3.Emergency Response Phone 4.Manifest TraekkiingQNuombef�rr''ry^ `,Cc <br /> WASTE MANIFEST ,a ., o ®U�)a'!8 C8 5 9✓ VES <br /> 5.Generators Name and Mailing AdG. ,ress R�,gpR XX LL enere s le ress(Adiferent Man maging address) <br /> AV5 S BEAN RDC SAME <br /> LODI.CA 95240 <br /> Generators Phone: <br /> 6.Transporter 1 Company Name - U.S.EPA ID Number <br /> v n OLUTIO S IN J D 0 8 0 6 3 1 3 8 9 <br /> 7.Transporter 2 Company Name r U.S.EPA ID Number <br /> MP ENVIRONUENTAL.91ERVICES C A T 0 0 0 6 2 4 . 2 4 7 <br /> B.Designated Facility Name and Site Address ""' U.S.EPA ID Number <br /> VEOLIA ES TECHNICAL SOLUTIONS, <br /> L.L.C. <br /> 1704 W.FIRST STREET <br /> Fadi sPhone: 62e 334-5i17 AZUSA,CA 91702 C A D 0 U 8 3 0 2 9 4 3 �. <br /> I <br /> ga go.U.S.DOT Descdp5on(inducing Proper Shipping Namm,Hamrd pass,ID Number. 10,Containers 11.TOW 12.Unit 3.Was a Cortes <br /> HM and Packing Cop(If any)) No. Type Quantity WLNaI. <br /> rc X f'lJNi993, ( ASTEFLAMMA.9LEU�]UIDS,n.Q.s.,3,14, F003 331 <br /> RD(D001)(LAS PACK) <br /> g ❑ fi I] j D '+tE i1 n ; ;3 it P DQUI r <br /> cul <br /> W X 2'UNigg2,WA.STEFLAMMABLUQUIDS,TOXIC,niG.s., D001 <br /> 3(6.1),!!(LAS PACK) <br /> DPA O 1 O F 3002O P 331 1 <br /> i <br /> 3.NON-RCRA HAZARDOUS 1n1A.STE LIQUID(LAB PACK) 331 <br /> ❑ 0 0 1 D F 04i 50 P <br /> 4.❑ <br /> ❑ <br /> 14.Special Handling Instructions arNAdditional Mfarmetion i)ERG:128W.il2436A:PEND-SIGNATURE1X55GAL 2)ERGA31W.112436A:PEND- <br /> SIGNATURE 1 X 20GAL 3)W 112438 A:PEND-SIGNATURE 1 X 55GAL+ <br /> ER.Service CoR acted by 0 STS <br /> I <br /> 15. GENERATOR'SIDFFEROR'S CERTIFICATION: I hereby declare thatea contents of gds consigmment are fultyand accurately described above by the propershpping name,and are classified,packaged, i <br /> marked and labeledlplacarded,and mem all raspects in proper condition fortranspod according to applicable btsmatlonaland rational governmental regulators.gexpon shipmenland I am the Primary <br /> Exporter,f certify that the contents of this consignment conform to the tams of the attached EPAAcknavledgment of Consent <br /> I pertly that the waste minimbation statement Identified in 40 CFR 262.27(a)(III ame a large quantity generator)or(b)(if I am a small quantty generator)is he. - <br /> GeneratorsrOfreroes PridaNTyped Nam - SpnaN �. , Month Day Year <br /> 1 12 <br /> _j 15.1 ems nal pm nd <br /> Impat to U.S. ❑io`prlfrcin U.S. Port of entylex;t <br /> Transporter signature(for exports only): Date IeaAr.g U.S.: <br /> w 17.Transporter Ackn aled9merd of Receipt of Matenals _ <br /> Tnensponer l Printed/Typed Name ...SIB Month CW Year <br /> a FRED WESEMAN 0 1 2 9 0 1 <br /> Tramporisr2 yped Name 0� t'���,Ao_ J- G� SigaWre Mmtlr Day Year <br /> C /may vr• O 0 I! <br /> 16.Discrepancy ' <br /> j life.Discrepancy Indicator,Space ry �Type ❑ l ❑Full Re <br /> ❑ Quant T e Residue Patial Re'ecton jectidn i <br /> i <br /> Manifest Reference Number. I <br /> 18b.Allemate Facility(or Generebr) US.EPA ID Numbs <br /> V I <br /> LL Fadlitys Phone: <br /> W life.Signature ofAltemate Facility(or Generator) MaAr Lay Year <br /> a I <br /> z <br /> H19,Heard=Waste Report Management Method Codes g e.,codes for harardous waste treatment,disposal,and recycling systems) <br /> ow 7 2. 3. C 4. <br /> �341 <br /> 20.Designs d Facility Ownerron0peratorCertificaU4 of receipt W In Nous masses coveratl by the manifest except as Medi ban 16a <br /> Prim ed Yom( <br /> EPAForm B 22 .3-05) Previous edifionsare Wdete. - DESIGNATED FACILITY TO GENERATOR j <br /> L <br />