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Illlll full IIII VIII I{III VIII full IlIII III!Illllll Iilfll II IIlI <br /> Please print or type.(Form designed for use on elite(12-pitch)typewnter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Numbe 2.Page 1 of 3.Emergency Response Phone 4.Manffeat Tracking Number <br /> WASTE MANIFEST CAD000633032 1 (800)321-8642 000269695WAS <br /> 1.00rt 9f"'IftTAMDUCTS LLC / MICHAEL PETER(;O "Vara'dH" ��treopullU res"LLC / MICHAEL PETE <br /> 2700 WEST WASHINGTON STREET 2700 WEST WASHINGTON S�REET <br /> STOCKTON, CA 95203 STOCKTON CA 95203 <br /> (209)466-4407 GEN: 120b04 SURVEY: 100376 <br /> Generator's Phone: <br /> Transporter Company Name U.S.EPA ID Number <br /> HERITAGE TRANSPORT, LLC—COOLIDGE IND058484114 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Des hated FiT Name and Site Address U.S.EPA ID Number <br /> A IT <br /> AUE ENVIRONMENTAL SERVICES LLC <br /> 284 £.,STOREY RD AZD081705402 <br /> 4 E, AZ 85228 <br /> F $ .. (520)723-4167 <br /> ga. 3f8 :bis6dptlon(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12.Unit <br /> M andPe0l�.tltoup(if en1)) 13.Waste Codes <br /> H <br /> No. Type Quantity WtNol. <br /> N:O S.UN1325 IIS(6ASOAMMABLESSOLIDS�0ORGANIC, 4 DM =580 P D001 D007 008 <br /> 07 <br /> I)008),E�R6#133, (4x559DM) D018 611 <br /> z 2. <br /> 3: <br /> 4. <br /> 14.Spa Handlin Instructions and Additional Information <br /> 1 —05 8177 (1)23,24,25,26 <br /> rX- <br /> z <br /> 11332929315 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> certify that the waste minimization statement identified in 40 CFR 262.27(a)if I am a large quantity generator)or(b)(it I am a small quantity generator)is We. <br /> 1Genem!? eror`sPrinPd/Typed Nam Signature Month Day Year <br /> 16.International shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Pf e /exit: <br /> Transporter s nature for exports only): Da vin U.S.: <br /> W 17.Transporter Admawledgment of Receipt of Materials <br /> W Transporter 1 Print Name re on ay eeaarr <br /> y �v.n - - I3 (1 a <br /> QTransporter 2 PrinteMyped Name Signature Monthay ear <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 181b.Alternate Fack(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> a <br /> LL Facil' 's Phone: <br /> W18c.Signature ofAJtemate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> H141 <br /> I <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the mandest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> \ `LO <br /> Ll -EPA 1187�111v Previous edition's are obsolete. D SIGNATED FACILITY TO DESTTION STATE(IF REQUIRED) <br />