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0 & <br /> M CD <br /> Please ptint or type.(Form designed for use on elite(124tch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIF&M HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manliest 7rackin Number <br /> WASTE MANIFEST cAL000Z61S421 1 14mw785a22s 0112 9598 F L E <br /> 5,GewaWs tanndd Malling Address <br /> eratoes Site ddress(if different than mailing address) <br /> Simpson <br /> 151 S AIRPORT WAY <br /> Stockton, CA 95206 <br /> Generator's Phare:91 62069664 <br /> A e�Tllcreal Trans U.S.EPA ID Number <br /> port Inc. (SV) CAR000070540 <br /> 7.Transporter 2 Cornpany Name U.S.EPA ID Number <br /> QQ ted U.S.EPA ID Number <br /> aLISGO o�I �.3�,��� <br /> PO Box 578,i�tuvy 92,11 Miles S Beatty <br /> $eatty, w 3 <br /> Face s Plxxre: 775553-2203 <br /> go. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Paddng Group(k any)) No. Type Quantity Wt.Nol. <br /> azar ous as e, o , .,(Arsemc, ea , DM P 0007 1 0004 D008 <br /> 08 x Chrondm),9,PG lII I 311 <br /> X ous as e,so .n.Us. ormum, ea , � DM P <br /> PGM —3 9p,3, <br /> i <br /> ALL HAZARDOUS <br /> F <br /> fERIALS BILLS At 11NE <br /> 4. <br /> TAB WILL STICK OUT <br /> OR 111-Rolm <br /> 14.Special Handling Inst uclions and N1bMUIbD tr 15M DocumentR. <br /> 1) 070128303.8 Mi.. ft I C IX5'0TM <br /> lea Mwn <br /> 2)ERG#171; 070128303-12123 SKJ-40Z"O Oy(Y V' 70TMj <br /> 15. GENERAT(Nt'9i0FFEROR'SCERTIFICATION:thereby declare that to contents of this aamigmrent arem)—was-L. <br /> above proper shipping name,and are c ossified,packaged, <br /> medced and lebeledlplacarded,end are In all respects in proper condition for transport accardng io apps vern I71ations.if export shipment and I am the primary <br /> Ex aMity Meat th contonts of Ws consignment conform to the terms of the attached edarrtlfy we*mirimb allon staterrrent Identified in 40 CFR 262.27(a)(if I am a large generahue, <br /> g on y ear <br /> C Jw <br /> Ie.International Shored ❑Impart U.S. ❑Export ho Psi of <br /> Transpoiter signature for Dale Moving U.S.: <br /> tY 17.Transporter wd of Receipt of Materials <br /> Year <br /> u&&&- <br /> re z <br /> Transporter 2 PdnWWypedSignature 001 Month Uay ea <br /> 1e.Discrepancy <br /> 18a'Discrepoinq Indiwfion Spew ❑ Quantity [:]Type ❑Residue ❑Partial Re echos <br /> j Full Rejection <br /> Mantled Reforence Number: <br /> 18b.Ahemate Facility(or Ganers" U.S.EPA ID Number <br /> V <br /> F Phone: <br /> 16c. (grreture of Alternate Fa (or Generai Month Day Year <br /> SZ 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposed,and recyding systems) <br /> 0 1. 2. ^ 3. 4. <br /> U <br /> 20.DasWoW Fadlity Owner a tor: erfi Von of Ipt of twzardous materials covered by the manifest except ae noted In Item 1 <br /> MiLl Tff MU tUAStgna <br /> EPA Form til Rev. Previous dflorts are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IFR QUIREO) <br />