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-. . Ud-04-'lb 'Ib:bO FROM- Coles Environmental 661-322-88830 <br /> T-454 P0005/0012 F-956 <br /> Please print or lype.(Form des'nod for use on olite(12-pitch)lypewfiler.) Fon Approved.OMS No-2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator lD Number 2.Pagolot S.EmelgencyResponso Phonc 4.ManifestltaciumiHomber <br /> WASTE MANIFEST ' C 7 1 209.460.0460 013435261 JJ K <br /> S.Generslofe Name andMailingAddress Generators SlleAddreae(f deerent than mailing address) <br /> PACIFIC SOUTM aST IRRIGATION <br /> 63372 S-dACKfON RD. <br /> STOCKTON,CA 93215 <br /> Genemloes Phone: <br /> 6.Tra0apodor l Company Neme "US.EPA ID Number <br /> George W.LOWDJ,IRC. CAh"0D0047019 <br /> 7.Trenapader2Company Name U.S.EPAF-10 <br /> s.Do`ognaOryJn caoDiy N.pmEnr�si(eAddrass ENVINONME IN 1A L U.S.EPAID Number <br /> 1[c.•511O9 W 117tftfI Streteitloru IIdC HEALTH DFP.ARTMFNT CAWX04.0,4^, <br /> LONG 6EAGH,CA 30813 <br /> Facaiys Phone: DM627.6729 <br /> go_ 91u.U.S.DOT Daeedptim(edudmg Proper$Ypping Noma,Housed Class,ID Number, 10.Canlainers "-Total 12,Unit <br /> HM and Pacling Group(fady)) 13.Mere Codas <br /> No, Type QeenOry WtNol. <br /> X I. (N 1}S3bVASTE FLAMMABLE UQUIO It. o,s. (AWlres)ues) 3 PGii DM , DWI <br /> ;cue 2 <br /> 3. <br /> 4. <br /> 14.Spedal Hand q lnsWclions endAddidonal mfortnagoA <br /> --T <br /> ERGY?128 Tetraliyrlro Unt&Methyl E1hy1 Ketone PVC pipe glue <br /> USE GLOVES PROFILE INVOICE# AS-o'36 <br /> 15. GENERATOR'S!OFFEROR'SGERTIFICAT10N:Iherabydaclere OellhemnlMkofthisconsignmentamidiyauda=ra(elydescdbedebovabyowpmpershippingname,afdafedeesifiad,peckaggsd, <br /> marked end tabstedlplacardctl land are to at re3pecte In perpercomiillon for ganspoitacWMng to applicable inbowiloneland negonal governmental regulations.If expodaNpmenl and 166 Ihe.Vmary <br /> EXpodeElcertlfy that lheoontenle oflhla mnsignmanl canfomtmlhplerma eflhe aVecM1ed FPAAdlnovdedgmehlofConsenl. <br /> I eadl(ylhel the wads minfmizebon galamentidentifiedin40 CFF 26227(e)(il am a large quandtygeneratod or(b)(dl am a amaVquanbTygeneralsr]is true. <br /> Genetalorar)Hemfs PMledffy ed Name Signature .. Month Day ear <br /> 1qA AA- A &i a!S 1 % O, a I <br /> W r 16.1alcon iona15Nprna s <br /> ❑Import b U.S. ❑Fspottfram U.S. PodofsnhyloxQ: <br /> s Tianspoaersignamre(forexpoTWonly): Daleleavng U.S.: <br /> �i I7.TranspodarAdmowladgmentofRem1plofMalaia4 <br /> g TransportIed/,7ypedN Signature Month Day Year <br /> In <br /> QTransporler2 PMled/typed ame I Signature Month Day Year <br /> F- <br /> .f} 18.Discrepancy <br /> I too.Discrepancy lndfraim Spero ❑ QusnW ❑Type ❑Residue <br /> ❑Pedial Rejacgon ❑FuQRe)ection <br /> Mahifesl Reference Number. <br /> 10b.Alternate Facility(orGcncmtor) U.S.EPAID Number <br /> J <br /> Na- Facifiys Phone; <br /> w fire,Signalureo(Allemele Facifty(or Generator) MoeN Day Year <br /> 4 <br /> z <br /> 10.Hazardous Wall Report MenagementMalhod Codes(I.e.,codes forhazardous waste treatment disposal,and feuyclingaysleme) <br /> 4. <br /> 20.Designated FadfityOrmeror Operator-Ceafficadon offecaipl,thazardous materials coveredbymomalreal t as noted in Item 18a , <br /> PMtedlTypetl Name S nal re Monty Dsy e9r <br /> EPAForm 0-22(Rev.305) Previouselillonsare obsolete. DESIGNATED FACH ITYTO D6 TINATION STATE(IF REQUIRED) <br />