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Form Approved.OMB No.2050-0039 <br /> Plea rGeneratoes <br /> . �nt or type.(Form designed for use on elite(12 pitch)tyreswriter.) 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> 1.Generator ID Number 003567510 J J K <br /> DOUS C.ALM10877 2W249-M <br /> EST <br /> Generator's Site Address(if different than mailing address) <br /> an�d�Ma�ilii Address <br /> ME tt/tAlMlllls <br /> ( f1�BCd,C1 0936 <br /> Generato s Phone: 209-249-M) U.S.EPA ID Number <br /> 6.Transporter 1 Company Name X10 <br /> 8r L!t U.S.EPA ID Number <br /> 7.Transporter 2 Company Name 0ADIM770M <br /> A6y EtiVKOf*119f U.S.EPA ID Number <br /> B.Designated Facility Name and She Address CAM7031=1 <br /> 5M S.9o*9 AMW CWP <br /> LIPiArIPW.CA 9M <br /> Facility's Phone: 323-2v r 4 Jcm10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, No Type Quantity Wt.Nol. <br /> HM and Packing Group(If any)) p 352 <br /> 1. Non wSSW:SW M&ft I r4 000'1 *Mftd ftbdS) DD� CIF l 5-O None <br /> O <br /> W 2 <br /> Z <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling InsWctions andAddifional Information ERG*1171 <br /> 9.wasw&&is,dam � neeed wilt, MM"'­7 73 /,,3 4 <br /> ent are full and accurately described above by the shipping name,a d are classified,packaged, <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this-consignment Y <br /> marked and labelediplacarded,and are in all respectsnt conform to the onterf orof the ortattaccording <br /> ched EPA Acknowledgment edgment of Conslentd national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents-of-thisstate 9 if I am a large quantity generator)or(b)(ITam a s all quantity generator)is Month �y Year <br /> I rtity that the waste minimization statement identified in 40 CFR 262.27(0)( 9 q-- rySign re 10-7 <br /> ,/ <br /> Gen r oes/Offeror's Printe N <br /> ------DExp_ort from U.S. Port of entry/exit: <br /> J 16.I emalional Shipments Import to U.S. Date leavin S.: <br /> F— <br /> Transporter signature(for exports only): <br /> Month Drrray�rr Year <br /> W 17.Transporter AcknoWedgmentof Receipt of Materials Signature �-7 `y <br /> Transped Name I <br /> ��Y Month Day Year <br /> O <br /> a Signature D� Q <br /> Z Transporter 2 Printed/Typed Name <br /> H <br /> 18.Discrepancy ❑Par4 Rejection ❑Full Rejection <br /> 180.Discrepancy Indication Space Quantity <br /> ❑Type ❑Residue <br /> Manifest Reference Number: U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J <br /> V Month Day Year <br /> u- Facility's Phone: <br /> W 18c.Signature of Altemate Facility(or Generator) <br /> Q <br /> O 19.Hazardous Waste Report Management Method C 3. <br /> odes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 4 <br /> Z <br /> w2. <br /> 0 1. <br /> F ' Owner or Operator.Certification of receipt of hazardous materials covered by the manifestnure <br /> cept as noted in Item 180 <br /> Month a Year <br /> 20.Designated acil <br /> P' d/i ped Name% e / Sfi�7 <br /> DESIGNATED FACILITY TO DESTINATION STATE (IF REQUI. D) <br />