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• c I <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 0 2 7 4 0 0 3 2.P�Q 1 of 3.Emergengr Resp�oonnse Phone 4.Manifest TracklNumber <br /> WASTE MANIFEST (?09) 9a3-9144 012"172979. FLE <br /> 5*jrgt IfVnd&-j*ess *" rM(if different than mailing address) <br /> 86 E LOOMS AVENUE 85 E LOUISE AVENUE ( i <br /> LATHROP, CA 95330 LATHROP, CA 95330 <br /> Generator's Phone (Z09) a8��9144 <br /> 6.Transporter 1 Company Name U.S,EPA ID Number <br /> BELSHIRE CARO 0 418'3 9 13 <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> De' nat aal' Name and Sit ddress U.S.EPA ID Number <br /> qY� Q lis V-6 t fatty N V T3 3 0 0 10 0 0 0 <br /> 778 383-Z2 9 <br /> Facility's Phone: <br /> (773), 332-2202)' p <br /> 9a. 9b.U. bon(indu('mg Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM a add Gany)) No. Type OuanEty WtNol. <br /> s• D 988 *Dols <br /> � <br /> abio t,''a &abiis itpaata4 *itb <br /> pe 18arions) : <br /> z 2. • <br /> w <br /> c9 <br /> 3. <br /> 4. <br /> 1 S aI H dli In tructions i G n <br /> ira gniI fs a vaur naafi defined in ft&te and railer and <br /> 40 CM 260.10. DOla aode repras*=* Disposal Restr s <br /> wasW that is ACRl idaitieA! bine not <br /> mx <br /> R+CR& regulated. PRWILE 8 0708187-0 Z)<55 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desc bed above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intema*nai and national governmental regulations.If export shipment and 1 am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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)(dl am a small quantity generator)is true. <br /> Generatoes/OfferoesPri Name S' Month Day Year <br /> q 1 <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> LU <br /> 17.Transporter AdumvAedgment of Receipt of Materials <br /> F— Transporter 1 PrinledrTypeda Signature Month Da Yaca <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy I. <br /> tea.Discrepancy Indication Space ❑ Otrantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q I <br /> Z <br /> US19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 20.Desgnat Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> Prat ante Sa Sig M <br /> �Y <br /> I f� <br /> EPA Fo 8700-22(Rev.12-17) Previous editions are obsolete. TRANSPORTER COPY <br />