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-Farm Approved,QMB Na.2050-0035 <br /> Please print or type, 4,Man estTra In N bAr ,. <br /> 2.Page 1 of 3.Emergency Response Phone � <br /> it.GeneratorlDNumher , , ' �L� <br /> UNIFORM HAZARDOUS � 51 OJ-U1 -2128 <br /> WASTE MANIFEST ! . 2" 640 Generator's Site Address{lf different than mailing address] <br /> 5-Generator's Name artd Mailing Address ' <br /> rata( Ten aatu3 LWnb&f <br /> Sidcilop'CA95� <br /> Generators Phare: 209-234-7,100 U.S.EPA la Number <br /> s.Transporter 1 Company Name M000340010 <br /> a 19 sky E."Wroame tal solullons u.s.DPA ID Nurnher <br /> 7.Transporter 2 company Name t01K 435 f42 74.2- <br /> r=-t0 1n*1t1ft1 sawke U.S.EPA ID Number <br /> 8,Designated Facility Name and 5itekddress <br /> Ltd EzaICN� <br /> "OPY 30611 miles soffit of <br /> Facifit/s Phane: 7752Z x <br /> 1U.Containers 11.Total 12.Unit 13,Waste Codes <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, Type Quantity wt.Nol. <br /> HM and Packing Group(If any)) No. yp <br /> 3 S 2 <br /> Non-RCRAHaV§i1-d0USVVaSt0.SCfid (0405) <br /> z 2. - <br /> LU <br /> & <br /> 14 S� a ap¢jiqtInsUuotions and Add p��rtfprrr�hgg <br /> PMR0 0 � - <br /> ER43ENC "CON TACT JEFF RHODES <br /> Y <br /> 15- GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and tabeledlplacarded,and are in all respects in proper condition for transport according to applicable lntemafionaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. <br /> certify Thal the wasle minimization statement identified in 4D CFR 262.27(a)(91 am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generatorsl0ffer❑ts Printed/Typed Noma:; Signalure -- Manlh Day Year <br /> 16-Intemalional Shipmenis Import to U.S. ❑Export from U.S. Port of entrylextt: <br /> t- Date leaving U.S.: <br /> Transporter signature(f❑T exports only): <br /> 9Z 17-Transporter Acknowledg ment of Receipt of Malerials <br /> L Signature rI l Month Ray` Year <br /> Transporter 1 PdnledfTyped NameEL <br /> f r <br /> r <br /> Transporter 2 PrintedfTyged Name <br /> Signature I Month Day Year <br /> J- <br /> 18.0iscrepancy <br /> 18a,Discrepancy Indication Space El ouantity ElType ❑Residue 0 Partial Rejection Full Rejection <br /> Manifest Reference Number: _,g <br /> 18b.A6ternate f=acility(or Generator) U.S.ENq tD Number <br /> U <br /> Facility's Phone: Month pay Year <br /> LU <br /> 1t1C.Signature of Alternate Facility(dr Generator) <br /> 4 <br /> Z <br /> V3 %Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C3 LW 1. 2. 3. 4. <br /> 20.0estgnaled Facility Ovuner or dperator:Certification of receipt of hazardous materials covered by the manifest except as naiad in Item 19a <br /> Day Year <br /> PrintedfTyped Name <br /> Signature Month <br /> EPAForm 870U-22(Rei•12-17} Precious editions are obsolete. GEVE TOW�INIT�IALCO�Py <br />