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• <br />Please print or type. (Form desianed for use on elite 112 -Ditch) tvoewriter.l <br />• <br />From Annrn -,I ALAR Nn gnnn_nn a <br />u)�ksnrrrcurra+.r�rrr tvvcatrnwarunalAtc(ttltt€.tUttttu) <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />r <br />WASTE ,(FEST CAL0002 W21 <br />1 <br />14.1111w4estTradking <br />1-MMM5 <br />008826990 FLE <br />U*WaraM,r'a Name and Melling Address Generators Silo Address (N different than mating adtlreas) <br />SW <br />5155 8 �WA Y <br />Stockton, CA WIN <br />Generalors Phone: 91 <br />rarrsporter 1 y rrn U.S. EPA ID NumberAdlentmd i lemiCd TIVIMPOft kw- {t3V) .. <br />CARt1000TO540 <br />7. Trasspwk.r 2 Company Name U.S. EPA ID Number <br />8. <br />usdlated Facility and Site Address U.S. EPA ID Number <br />rNew3da hp <br />11 Mons Beeltty NVT390010000 <br />Facility's Phone: 7754* <br />ga_ <br />HM <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />mrd Packing Grafi (deny)) <br />10. CordaMers <br />11. Total <br />12 Unit <br />13. Waste Comes <br />No. <br />Type <br />Quantify <br />Wt./Vol. <br />atim ERM MOW— <br />W0M <br />2N- In <br />3 <br />4, <br />14, Special Handling "uctxm and Additional Information <br />PM*wt 7111/58 Dow" 501!: D®1 <br />I)ERK 0M31b70611=%,W u S-5� fi <br />1 J'4 <br />� 6ff <br />2)ERM% 070131=411= 011 t j <br />15. GENERATt2ft MFFEROWS CERT1FlCATION: I hereby declare that the contents of this consignment are Wand accurately described above by the proper slipping name, and are classitied, packaged, <br />marked and labeledlplacarded, and are in all respects M proper condition for transport according M applicable kdematio nal and rnationakvenmerdai <br />� regulations. If export shipment and I am the Prknary <br />Exporter I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br />f ce 'ly iv the waste rrnknizat'an statement ified in 40 2_9.47(a) (if 1 am a large quantity generator) o (b) (d I am a small Quantity ganeraklM true, <br />jes ¢lt arms <br />y ear <br />aur (_tj2y�A <br />AJ1 <br />(J11 OI <br />—r <br />ZImport <br />16. liftoa`,wmai Shipments <br />M U.S. ❑ Ezpat from U.S. Port of ent A <br />Transporter 'e (o oni Dale leaving <br />17. TransporterAckwMedgmerd of Receipt of Materials <br />ITranIll <br />7r s a s PriNamelar¢ r <br />AG7 <br />Z <br />Q <br />Name lure Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity Type ❑ Residue EJ Partial Rejeclicrn LJ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />Facilit k Phone: <br />a� <br />Z <br />18c. Sign dura of Alternate Facddy, (or Generator) Month Day Year <br />N19. <br />Hazardous Waste Report Management Method Codes Q.e., codes for hazardous wale treatment. disposal, and recycling systems) <br />p <br />1, V\O 9,A_ <br />2 �_q <br />34 <br />20. Designated Facility Owner a Operator: Certification of receipt of hazardous materials covered by the wariest except as noted in Item 189 <br />Prirdedlfypod Name Signature Mont h flay Year <br />\cn 4 g <br />EPA <br />Form 87M22 (Ray. I-MrWPvirum whNvis are nhsnlrir <br />u)�ksnrrrcurra+.r�rrr tvvcatrnwarunalAtc(ttltt€.tUttttu) <br />