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Please print or type.(Form designed for use on elite(12-pitch)typiewiler,) - Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2,Page 1 of 3.EnsaWncy Response Phare t TrackingNumber <br /> WASTE MANIFEST C 4 L 0 0 0 2 )B 0 7 613 1 1-800.424.930(t 1013482538 JJ K <br /> S.Czeneator's N�me and MailirgAdtlress M b aron 10U .a Genaretofs Ad dress WdiFemmlhan mating address) <br /> evvay nc. 5afeuvay UPI#2107 <br /> 5913 Stoneridge-Mall Road:Atm: Sharon Plouffe 6425 N Fade Ave <br /> Pleasanto+l CA 94525 Stockton CA. 95207 <br /> Genemws Phone. 2 0 9 4 7.2 - 8 6 0 0 <br /> 6. re—MP drn card pany Name U.S.EPA ID Number <br /> Environmental 1-091511cs, Ino. A P, 0 0 0 2 1 7 5 1 <br /> 7.Transporter 2 Company Name .S. PA ro Number <br /> 8.f atal Facility Name�gld Site Address U.S.EPA ID Number <br /> Mato <br /> KKeckICIM3 SServices,Inc. <br /> 180 t,1f.Monte A-emn, <br /> 9100rrengton CA 92316 <br /> Facites Phone: 909 421-2012 C A, 0 9 3 2 4 4 4 4 _d 1 <br /> 9a. 9b.U.S.DOT Description(Inducing Proper Shipping None,Hazard pass,ID Number, 10.Consiners <br /> u <br /> HM and Packing GmuP(ferny)) Tecrl 12.Unit 13.Waste Codes <br /> No. Type Quantity WINd. <br /> 1UN3175,Solids Containing flarrnbble liquid,Ii(gasidiesel filters, 4�2 <br /> o absorbent pads) MM <br /> 4.1.PGII W� Dm t7'50 P <br /> z <br /> ':FILTER RECYCLING SERVICES'RIALTO FACILITY,EPA <br /> #CAD982 44489 NAS �ORr n�(� y )r •1 <br /> 'AND WILL ACCEPT THIS WASTE AS SHIPr 0 <br /> 4. <br /> 14 Special Handling Instructions andAddlfianalinformation 1}(S)uaslDieselPikers,hoses,asborbentload- 11091417 ERG#1i3 0101#166807-i'.i <br /> I X SS <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 labeledlplecarded,and are in all respects in proper condition for transport according to agplicable Inamedonal and national govemmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment carom to the temis of th attached EPAAdvvh"gment of Consent. <br /> I cedty Mat rhe waste minimization statement dentified in 40 CFR 26U7(a)(N I am a large quantity generator)or to)('dl am e I quantity genera"is We. <br /> GeneratorsrOff"es Prime lrryped Name Sgnafure Monts Day Year <br /> �.I/- l c111 ( CA Iwf <br /> —1 16.International Shipments <br /> F ❑ImporttoU.S. ❑Expalhim U.S. Pon Oferbyledt <br /> Z Transponer slgnafure(for exports orgy): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter PdnWyped Name11 ture A nth Day Year <br /> 1�L 'I-) I v1 L r fix l 1.7� �'. <br /> mmpcder n ame Signature Monts ay Year <br /> 1 18 Dleaepancy <br /> 18a,Oisaepalcy Indicet'ron Space ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Releutlan ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPAID Number <br /> J <br /> V <br /> u Facility's Phone: <br /> 18c.Shimsture of Alternate Facility(orGenerator) Month Day yee, <br /> a <br /> z <br /> h19.Hazardous Waste Report Management Method Cabs ll.e.,codes forhatardous waste treatment,disposal,and recycling systems) <br /> p 1. 2. 3. 4. <br /> 20.Dwignated Fadtry Omer or Opemtor.C 'tmtlon of moiplof haadous materials covered by Me mangest e t as rded in tea <br /> illi nto me Sig I I <br /> i� <br /> EPA Forth 8700.22 1Rev. ) revious edlfioYts are sate. E I NATE CILITKTO GENERATOR <br />