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TS..C- 09347. 156:0 <br /> Please prints type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST M991082302 1 600-748.7449 1003235546 JJ K <br /> 5.Generamis Name and Marlin Address Generators Site Address(it different man mailing address) <br /> CONNELLMOTOt�TRUCK CO..INC. 2211 N WILSON WAY <br /> P.O.BOX 8467 STOCKTON,CA 85205 <br /> STOCKTON.CA 95208 <br /> (3mernoh Phone: 209488.2411 <br /> 6.Transporter t Company Name U.S.FPA ID Number <br /> SHOP HAZARDS SOLUTIONS CA00006464 W <br /> 7.Transporter 2 Company Name - U.S.EPA ID Number <br /> S.Oe d tftt6ftbVAsLLC. U.S.EPAIr�99er B3 <br /> 11855 VM TE ROCK RD, <br /> RANCHO CORDOVA.CA 95742 <br /> 916-351-09M <br /> Fardti aPhane' <br /> ga. 9b.U.S.DOT Deuription(including Proper Shipping Name.Hazard Gass,ID Number, 10.Containers 11.Tool 12.Unit 13.Waste Codes <br /> NM and Packing Grcuptifany)) No, Type Quantity WtNol. <br /> 1. DM 55 G D001 F1303 214 <br /> 0 <br /> 0-q <br /> z z. <br /> W <br /> 6. <br /> 4. <br /> 14.Special Handling Instructions an dieon dl lnfemation <br /> PROFILE NR J91 <br /> APPROPRATE PROTECTIVE CLOTHNG <br /> SEE ERG 9128 <br /> 15. GENERATORWOFFEROR'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 IabaMNplacarded,and are in all inspects in proper cordon for transport according to applicable international and national governmental regulatioundi If expcn shipment and I am the Primary <br /> Eryoder,I certity,that the contents of this consignment conform to the terms of the attached EPAAckneeledgmeni of Consent. <br /> I pertly that the waste minimization statement identfied in 40 CFR 26217(9)(dl am a rage quantity generator)or(b)(d1 am a small quantity generator)is true. <br /> Geper4ol+ rs P�nleM NgrthE� SigQW Month Day Year <br /> DA <br /> _+ 16.IpInnttVer International Shipments /!lam .C�1 <br /> F ❑ImpartIo U.S. ❑Eepad from U.S. Pon of entry/exit <br /> Z Transporter sgnalure(for experts only), Date leaving U.S.: <br /> w 17.TransponerArkno'Medgment of Receipt at Materials <br /> Tren 1 PdntedRyped come S Mgr d Day Year <br /> 6 <br /> r <br /> QTransporter 2 PnntedfTyped Name Signature Month Day Year <br /> rT <br /> F <br /> i18.Ofsorepancy <br /> 16a.Discrepancy Indication Space 1:1Quantity Elva ❑Residue ❑Partial Rejection El partial Rejected <br /> Manifest Reference Number <br /> l8b.Alternate Faddy far Genwamr) U.S.EPA ID Number <br /> J <br /> U <br /> LL Fai Phone: <br /> w ISc.Signature of Alternate Fadiry(or Generator) Month Day Year <br /> ti <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,ancestor hazadous waste treamenb disposal,and recycling systems) <br /> 1. 2. 3. 1. <br /> 20.Designated Fad5ty Owner or Operator.Certificated of receipt of hazardous materials covered by the maddest except as noted in Item led <br /> 1 Pdn eN ypad Name Sg sure Mem Day Year <br /> of .4ir �AA" la 122Q7 <br /> EPA Form 8700-Z2( a¢3-0 ) Pvious sareobsoete. _ DESI ATED ACILITY TZYdESTINATION STATE(IF REQUIRED) <br /> 10159.2169 <br />