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160400-16 <br />Please print or type. (Form designed for use on elite 112 -pitch) typewriter.) <br />61 2481079 <br />Fonn Approved. OMB No. 2050-0039 <br />EPA <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />14. Manifest Tracking Number <br />WASTE MANIFEST CAH111001044 <br />1 <br />1 <br />( 877) 577-2669 <br />00 DAT <br />5. Generators Name and Mailing Address Genealoes Site Address (if different than mailing address) <br />SAN JOROUIN CO. PUBLIC VORKS - OR16IN. STOCKTON PHHUCF SAN JOADUIN CO. PUDLIC VORKS DEPT/STOCKTON PftCE <br />1818 EAST HAZELTON AVENUE ?850 R.A. BRIDGEFORD STREET <br />Generators Phone: STOCKTON CA 95201 (289)468-3866 STOCKTON CA 95206 12091468-3066 <br />G. Transporters Canpany Name U.S. EPA ID Number <br />21st Century Environmental Management of California, LP CAR000210617 <br />7.THer 2 Company Name U.S. ID Number <br />MkF G�6o S� Z <br />r r- -5ei-I1 ice <br />8. Desgnated Faelhy Name and Site Address U,S.EPA ID Number <br />RINECD CHEMICAL INC <br />1007 VULCAN ROAD-MRSKELL <br />Facili sPhone: BENTON AR 12015 (500 718-9089 ARD981057870 <br />ge <br />9b. US. DOT Desorption (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Conainers <br />11. Total <br />12, Unit <br />NM <br />and Packing Group (h any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />-? • <br />1' UN1253 PRINT RELATED MATERIAL 3 PGII DOT-SPI1624 <br />612 <br />I <br />X <br />I <br />CF <br />%03 <br />P <br />w <br />z. <br />w <br />3. <br />4. <br />L <br />I <br />14. Special Handling Instructions and Additional Information <br />(1) 140565771-02 - ER61126) PRINT RELATED MRTERI. ALL POSTE 15 EXEMPT HOUSEHOLD HAZARDOUS URSTE PER 40CFR251.4b. <br />PQ IrH-Ca re <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately encased above by the proper shipping name, and are carolled. packaged, <br />marked and labeledlplawded, and are in all respects; in proper condition for transport according to applicable intemahonal and national governmental regulations. II export shipment and I am the Primary <br />Exporter, I ceNly, Nat the mnlents of this consignment contain to the tarots of the atraeled EPA Acknowledgment of Consent. <br />I certily that the waste minimization statement Identified in 40 CFR 262.27(x) (h I am a large quantity generator) or (b) (if I am a small quanldy generator) is We. <br />GeneasoesfOffemes Printecirryped Name D v 0 , Signature Month Day Year <br />.-. / 2--Z';-'1- <br />--Z'� L- 1 1111 1 g L <br />16. International Shipments <br />❑ Import to US. ❑ Export from U.S. of enlrylexit <br />i <br />_ <br />Transporter signature (for exports only): Date leaving U.S.'. <br />C6 <br />77 nsporterAckmMadgrtanl of Receipt of Materials <br />G <br />Tat Prim ikdRyp come SgnaW Man1h Y <br />Qo} <br />W <br />Th <br />Tanspo z LLdRyped Name Signature Mgy{p Day Year <br />C <br />tA <br />4. <br />1g. Discrepancy <br />j <br />18a. Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Pani at Rejection ❑Full Rejection <br />Manifest Reference Number. <br />t8b. Alternate Fadlity (or Genealor) U.S. EPA ID Number <br />J <br />U <br />LL <br />Facility's Phone: <br />Maj <br />18c Signature of Alternate Facility (or ator) Month Day Year <br />a <br />Z <br />43 <br />19. Hazardous Waste Report Management Method Codes (i e.. codes for hazardous waste treatment, deposal, and recycling systems) <br />G <br />1. <br />2. 3, <br />4. <br />20 Designs anility Omer or Operator. Cerifcation of remipt of hazardous materials covered by as man lest except as need in hem 18a <br />-Na.. <br />1 <br />rinted7fype signature. Month Day Year <br />" I <br />Fan 87OD-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />