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Please print or type, Form Approved.0M8 No.20 50-0 03 9 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page t of 3.Emergency Response Phone 4.Manifest Tracking <br /> Number �'�3 <br /> WASTE MANIFEST GAL000408a2 I 2U"I#-R3O3 tl ! J E 'G V ) G B F <br /> ie ate r'S <br /> Name and Mailing pd Generators Site Address(d drHerem than mailing address) - <br /> LOPEZ CUSTOM COMPOSI FE <br /> �2Zi E. MARIPOSA RI] <br /> venerator's Phor� 0149303 STOCKTON, CA 95215 <br /> 6.transporter T Company Name <br /> U.S.EPA ib Number <br /> AMIERICpW IrfALLIE'y WASTE OIL, INC. CAfiU4Q27230� <br /> 7.Transporrgr 2 Company Name <br /> U.S.EPA YD Number <br /> SI'ERICYCLE SPECIALTY WASTE SOL LMOPIS, INC tand.�00E]y 1f]32A <br /> &-(Jesrgnafed nd SAddre <br /> FacllTY Name aitesq <br /> U-S.EPA ID Num <br /> [3EM-R NCHO CORDOVA, LLC. ber <br /> 14855 WHITE ROCK RD. 771J <br /> RANCHO CORDOVA,CA 95742 <br /> Facility's Phond.41&351�Q <br /> ga. 9b-U.S.DOT Clasdption(including Proper Shipping Name.Kazard Class,Id Number, 10.Containers <br /> HM and Packing Group(i(any)] 1f.Total i2 lhlil 13.Waste Codes <br /> 1, f t° TYpe Quantity t+4ry 1Vcf, <br /> ` RG,kR41993,WASTE FLAMMABLE LIQUIDS,N C1 5„'q, P(Zli• 1 �� 55 G DOW F17O3 1212 <br /> ACETONE, RESIN <br /> 2. <br /> 3. <br /> � 4 <br /> A 4peeial Handling Instructions andAdditional lnformahion <br /> PROFILE# Mob18-u.i WAS7EACETDNE ERG0128 <br /> EMERGENCY CONTACT:NOE <br /> 5. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby declare thal the contents of This consignment are fully and accuralery descnbed above by fhe proper shlppmg name,and are cassrfred packaged, <br /> marked and tabeledlplacarded,and are in all respects in proper condilion for transport according to applicable Inlemalional sod national governmental regulations.If export shipment and I am the Pnmary <br /> Exporter,I certify that the contents of this consignment conform le the terms of the attached EPAAcmowledgmenl of Consent. <br /> I COMM that the waste minimization slatement identified In 40 CFR 252.27(x)(if I am a targe quantity generator)or(b) all quantity generator)is true. <br /> '6enera sfl)fferor s Printed/Typed N�0#_ <br /> Signature North Day year <br /> �7s"Rr - <br /> i.Intemational Shipmen(s <br /> ❑Import to U.S. ❑Fxporl from U.S, Port of entrylexit; <br /> ransporter signature(for exports only): Date leaving U.S., <br /> '.Transporter Acknowledgment of Reoaipt of Materials <br /> Insporter 1 Prim erne Signalure � lh pay Yea <br /> nsportlK PrinledTyped Nerrm a r <br /> nth Day Y <br /> Discrepancy r �r <br /> -Discrepancy Indlcation Space Quantity ❑Type ❑Residue ❑Partial Releefion ❑Fufl Relectlpn <br /> Manifest Reference Number: <br /> Altemale Facility(or Generator) U.S.EPA ID Number <br /> lityls Phone <br /> Signature ofAftemateFacility(or Generator) Monk Day Year <br /> c <br /> awdot s Walde Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Z 3• 4. <br /> Ll IL <br /> rsignaled FadGly D++ner or Operalor.CeAftation of rercelpi of hazardous materials covered by the manifest except as mated in Item 18a <br /> :11 Typed Na Signature <br /> t t —� ` R - - -- - -• Nlnnrtz nav vas. <br />