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Peast a print or type, <br /> UNIFORM HAZARDOUS 1 . Generator ID Number- Form Page 1 of 3. roved. OMB No. 2050-0039 <br /> Ema�yency Response Phone 4. Man Tra ng Number <br /> WASTE MANIFEST 62 2^ � 6 4 � G BF <br /> S. Generators Name and MaRingAddross " — Genera s e nrss (IFdifferent Than malgng address) <br /> Yf)S1ndi7r' AVE ARCO AM fYN? <br /> 171 '1 E, YOSEMITE AVE <br /> .Generator's Phone: MANTECA, to 9533(1 <br /> 6. Transporter 1 r' U.S. EPA ID Number <br /> 7. Transporter 2 Company Name <br /> U.S. EPA ID Number <br /> 8. Designated Facility Name and U.S. EPA ID Number <br /> 0EM• HANCHO C ORDOVA, LLC, <br /> 11866 VVHITE ROCK RI), 0A{1MB(M.41K*j <br /> Fadfii (sPhone: (V"CH0 CORDOVA, CA 95742 <br /> 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. onta <br /> Ciners <br /> HM and Paddng Group (N any)) No, Type Quantity 12. Unitit 13. Waste Codes <br /> 1. <br /> FnioFtG?, 01`4112438WNA.rTf' PFTROI. EttM DISTK LAI ES, N 0 S , 34 Will , t LIM Sri C il'1 ? • <br /> f Air,5;O71 INF . Illt?SFt <br /> Z 2 <br /> W <br /> fa <br /> 3, <br /> 4. <br /> 14. Special Handling instructions and AddlSonal Intortnation <br /> HkQFILE# 796tlf"2 WArt:le & GA:S f:'N(WF 1213 <br /> l MERGENVY CONTACT• JASBIR <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately dew-dbed above by the proper :hlpping name, and are dauffied, padraged, <br /> marked and labeledfplacarded, and aro In all respects In proper condldon for transport according to applicable International and national governmental ragulatim, If export shipment and I am the Primery <br /> Exporter, i tartly that the contents of this consignment oonrwm to the terms of the attached EPAAdmowledgment of Consent. <br /> I cert fy that the waste mtnlmtretion statement Identified In 40 CFR 262M7(s) (111 am a large quantity generator) or (b) (di am a small quantilygeneretor) is two. <br /> Ganerator's/0iferor's Pdnted/iyped Nemo _ Signatureie <br /> Month D <br /> S �" Lam" 1 t^) I,; D ; —( --- ^ Year <br /> r 16. International Shipments V' 'e '� t <br /> r- ❑ Import to us, Export from U.S, Port of enhytexit OEM <br /> Transporter signature (forexports only); Date leaving U,S,: <br /> w 17. Transporl"AdmMedgmenl of Receipt of Materials <br /> i <br /> Transporter 1 PdntEd11 y. Name lgneturo Month Day Yea <br /> el e <br /> ICL C <br /> Transporter Slynahne th Day Year <br /> 18. Discrepancy <br /> ills. Discrepancy Indication Space EJ quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> 18b. Alternate Facility (or Generator) Manifest Reference Number. <br /> .J <br /> U.S. EPA ID Number <br /> V <br /> Facilltys Phone: <br /> w 180. Signature of Alternate Facility (or Generator) Month Day Year <br /> y19. Hazardous Waste Report Management Method Codes Q,e„ codes for hazardous waste treatment r8sposal, and recyd(ng systems) <br /> 0 1' 24 31 Notice : State of California requires <br /> generator to photocopy and mail to <br /> 20. Designated Facility Owner or Operator. Certification of recelpt of hazardous materials covered by the manifest except as noted in Item 18a DTSC with 30 days: <br /> Print yped Name Signature <br /> p .o Box aoo <br /> Sacramento, CA 9SS12-0400 <br /> EFTA Form 8 M(Q2 (Rev. 12-17) Previous ed llons are obsolete. GENERATOR'S INITIAL COPY <br />