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DTSC. 0106.5. t-.5.9:8 <br /> Please print or type.(Form designed for use on elite(12-pitch)lypewriter.) Form Approved.OMB No.20WW39 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Ernetgancy Respatse Phoma 4.Man Tracking N <br /> WASTE MANIFEST CA5/1/ 039 1 (926) 371-5747 0 0 3 6193 0 4 JJK <br /> 5-G <br /> Merator's Nana and M Address Generators Slle Address(If different than mailing address) <br /> �[DA iS...;.w 1 � o i C6 of 6nr&PiE0ey� S BEAD�Rfl J00 Fcsi`Son-�x}-W or /3ai <br /> It.�l E �zr 6 Su-k--caw 74(kl,(24. 95,31-4 <br /> GeneratofsPTrone — Z� <br /> 6 Transporter t Compmny Name U.S.EPAID Number <br /> RAMOS ENVIRONMENTAL SERVICES CAD 044­003 556 <br /> T.Transporter 2 Camparty Name U.S.EPA lD Number <br /> 8.Deslt mated Fadliy Name and Sita Address U.S.EPA ID Number <br /> CHEMICAL WASTE MANAGEMENT, INC. <br /> 35251 OLD SKYLINE ROAD, KETTLEMAN CITY, CA 93239 <br /> Fadfitys Phare: (800) 222-2964 CAT 000 646 117 <br /> ga 9b.U.S.DDT Desa0ion(including Proper Shipping Name,Hazard Gass,ID Number. io.Containers 11.Tocol 12.Unit 13.Waste Cedes <br /> HM and Pad"Group(d any)) NO. Type Quantity wt.Ald. <br /> 0 1-/J Rr-eq .2 <br /> �,Z 001t Pr7 c! P <br /> = 2. <br /> 3. <br /> 4, <br /> 1 <br /> 14.Spedal HWIng Instructions and Additional lnrmmenon HANDERR9 TO BE TRAINEDAND USE PPE. S 0 <br /> 9 S 1' / y5l <br /> 15. CENERAMR'SIDFFEROWS CERTIFICATION:1 hereby declare that the contents of this cxtsignmenl are fully and accurately described above by the proper sh#Ing name,and are dasslfled,packaged, <br /> marked and Iabeladfpleramled,and are in all respects In properconditlon for bampott ac ord'mg to applicable Intemallonsland national goremnwtal regulatlarts.If export shtpment and I am the Primary <br /> Exporter,I certify Met the wtents of this consignment oonform to the temrs of the attached EPAAeknowledgmern of Consent <br /> I certify that the waste mInImizadon statement identified In 49 CFR 282.27(a)Cd I am a large quantity generator)or(b)(HI am a small quantity generra"Is M. <br /> General &Df1ew%PrintacbTyped Name Signature Month Day Year <br /> —j 16,International Shipments <br /> L]Irnpbrt to U.S. ❑Export)Iron V.S. Poet of entrylexlt: yt <br /> Transporter signature(for exports only): Data leaving U.S.: <br /> 17.Tmnspa wAdutoNledgment of Receipt of Matcials <br /> Transporter 1 PdntedlTyped Name Signature Month Day Year <br /> 8AI WO1 JDl6 <br /> Z Transporter 2 Priv yped Name re Month Day Year <br /> 18.01saepancy <br /> I&ourepancy Indian Space ❑ Quantity ❑Type ❑P.M. ❑PM d Rejectbm ❑FO Re(edlon <br /> Manifest Reference Number. <br /> 1 ft Alternate Facility(or Generator) J.S.FPA ID Number <br /> U <br /> Fadtifys Phone: <br /> 1 tic.Sig VW?o of kttemate Fad*(or Generato>) Month Day Year <br /> 19, s RqW <br /> Management Method Codas(l.e.,codes for trarardous waste tra4nrfit,disposal,and recycling systems) <br /> 1. 2, 3. 4. <br /> Oesig F iy er 0 tar Ce ' our of reralpt of hazardous matadors arvered by the i <br /> D <br /> EPA Fon► T0" 22(Rev �,,ed r ons are obsole 10594.0365 D IG TED FACILITY TO DESTINATION TE(IF REQUIRED) <br />