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Form Anuroved. OMB No. 2050-0039 <br />tPAFoMS/W-U(Kw3-U Priam seditonsamobs3lek. <br />DESIGNATED FACILITY TO DESTINATION STATE (IF .REQUIRED) <br />—;+ 14."a — <br />11- 11 <br />UNIFORM HAZARDOUS <br />1. <br />br N Number 2. Page 1 of 3. Enengavy Response Plane <br />4. Mar Tracking Number <br />0 0 8135372 J J K. <br />WASTE MANIFEST <br />0 0 0 3 1 9 4 5 9 4 <br />S. =raw$ Name and Man <br />Addn <br />c Sa,Ad -(d onumnlehan maoN adNess) <br />WEST VALLEY <br />i JT0 1 <br />1PA AND LUBE-WES197- .. <br />2615 W GRANT <br />NE R <br />DAD <br />TRACY <br />CA 96304 <br />Corwrabns Plane: <br />RM 4001 <br />B. Transporter 1 Company Re <br />U.S. FPA ID Number <br />7.TwapoMf2 ComparryN <br />qTAI -- <br />U.S. EPAID Number <br />8. Design@ Fality Name <br />SftAd <br />vass <br />U.S. EPA ID Number <br />SIEMENS WA <br />R TE HNOLOGIES CORP. <br />6375 SOUTH <br />YLE <br />VENUE <br />LOS ANGELE <br />CA 90MB <br />C A .D 0 9 7 0 3 0 9 9 3 <br />Fadkfys Phorre: <br />ga. <br />.S. <br />9b. UDOT Desai <br />(ndu <br />Proper Shppu g Name, Haard Gas ID N abet, <br />10. Conti <br />11. Tagil <br />12. Unit <br />73. Waste Codes <br />No. <br />Fm <br />Type <br />HM <br />antl Padmg Grap ( YI) - <br />OrsrrMy <br />V JW <br />i. <br />C <br />SOLIDS) <br />5 <br />NON-RCRA <br />US WASTE, SOLID (OILY <br />1 " <br />1 5p <br />Ty <br />wz <br />2. <br />3. <br />4. <br />14. Specel Hanrlfng Instruct <br />andA <br />dUonal brformalun <br />EMERGENCY <br />NT <br />T:CHEIMREC 1.800-424-MNAERC3*9B1:171PROFILE #9B1:AM9705 <br />OILY SOLIDS, . <br />ABSORBENT' <br />OAA IMM -APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br />\ J? <br />15. GENEUTOR'SlOFFE <br />INTSCEITIFICATION: <br />I hereby dedare that the omuen5 ofdas consignment are filly and amnmlely described above by tre paper shpping name, and are dessfied,packaged, <br />m2lrtedandMbeltdp <br />areh al respects in pmpercbmiton for transport eacordthg to applicable inMnatonal and rsdonal govemmental tegdatons. if expel shipment and am the Primary <br />Eyarter, l cehrfy txn tr <br />conlan <br />of this conrwment conform to the tarms of the atadhed EPAPtknowledgmenl of Corxmnl. <br />I ceNfy that tla walla <br />'pro smlement Itlentlfietl in 40 CFR?b22T(a) (dI am a fags quenaly gerremla) or (bJ (AI a smell quantty generate) H Ove. <br />Genemtoes/Oflerofe Printed <br />� <br />N r, <br />B' _7 <br />Month Day Year <br />3 2 ( f <br />J <br />15. I Shipmenb <br />Import to U.S. ❑ Export hnm U.S. Part eehty/exit <br />' <br />spweional <br />TranspMe: signaaaP (nae <br />Ns oMy <br />Date leaving U.S.: <br />¢ <br />17. Trxaporkr <br />of <br />ofMalerials <br />5 <br />TmnspoMs 1 PrintedrTyped I <br />&gnawm <br />Monti Day Year <br />Ulle <br />I <br />0d <br />a <br />QTmnsportef <br />2 Pnm Iypw I <br />IfnG <br />C/C <br />u signadae <br />Zt( <br />Month Day Year <br />K <br />H <br />Dsaepmay <br />i13. <br />1 an. D'saepancy Indication <br />❑ ❑ TYPa ❑ Residue <br />❑ Parted Rejeccon ❑ Ful Raped. <br />Manliest Reference Number. <br />181b.A ato Faahy(a <br />at,6 <br />U.S. EPA ID Number <br />J <br />V <br />Fadlys Phone: <br />I. <br />- <br />W <br />18c Signature afAltemale <br />(a <br />1 <br />Month Day Year <br />Q <br />z <br />N19. <br />IiamNws Walla Repa <br />amagen <br />w Metwd Cada (ca,codes for hazardas waste bmanank deposal. anrd mcydng systems). <br />0 <br />1. <br />2. - 3. <br />- <br />4. <br />20. Desi DwmOpen <br />tor. c tkadon of . t oflents wvered by to merdeat except a Dow in Item 1§1/ <br />. a.: . <br />PrBdedrTyped Name <br />0441 <br />NgnaM <br />,.. Month '.Day. Year <br />1 <br />tPAFoMS/W-U(Kw3-U Priam seditonsamobs3lek. <br />DESIGNATED FACILITY TO DESTINATION STATE (IF .REQUIRED) <br />—;+ 14."a — <br />