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1 1111111111 1111111-111111 H1111111111 11I1 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000409951 1 (801))326-1221 <br /> "%tM24 }W1t-D # 1188 / NICOLE MAHONEY RY1WY 10520 6 Gf dtlter�tf4 16lling addresA 8 / NICOLE MAHONEY <br /> PKWY <br /> STOCKTON, CA 95219-7227 STOCKTON CC�A�95219-i7F22217t3 <br /> Generators Phone: (219) 474-0119 GEN: 205A53 <br /> 6.Transporter Company Name U.S.EPA ID Number € <br /> HERITAGE TRANSPORT LLC - TS HAYWARD IND058484114 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> HERITAGE ENVIRONMENTAL SERVICES <br /> 284 E STOREY RD AZD081705402 <br /> COOLIDGE, AZ 85128-9205 <br /> Fad s Phone: (520)723-4167 <br /> 9a. 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 Packing Group(if any)) No. Type Quantity Wt Vol. <br /> 1. <br /> 0 X UN1993 WASTE FLAMMABLE LIQUIDS N.0.S. 131 ` D� F003 Olf 1 <br /> PG I I, (ACE ONE, ISOPROPANOL),ERG#1 h <br /> z 2. <br /> Uj X UN3248 WASTE MEDICINE LIQUID FLAMMABLE �� 311 P042 0002 <br /> TOXIC N,h S. ,3(6. 1),PGM, (ETHANbL, SELENIUM) <br /> ERG#131U031 U039 U112 <br /> X s. UN3249 WASTE MEDICINE, SOLID TOXIC �'� P P042 311 U002 <br /> N.O.S. ,6. �.,PGI I, (SELENIUM, SILVER),ERG4151 <br /> 0112 0122 U154 <br /> 4. <br /> X KUUUb , 845 <br /> TTcnanp' 7 <br /> 14.Special Handling Instructions and Additional Information <br /> 1.W1_01411813_LBR 2.W5_Q1413443_LDR 3.WG 01412925 LDR _ <br /> CL 'C�AAI C1237749316T <br /> 15. GENERATO OF EROR'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 labeled/placarded,and are In all respects in proper condition for transport according to applicable international and 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)('dl am a small quantity gene r)is true. <br /> Generators/ s n ype Name nor on y Year <br /> rrdb -t ntZ <br /> r.IntematIonal St#ments <br /> ❑Import to U.S. ❑F_xport from U.S. Po of enhy/exit: <br /> Transporter signature for exports only): Date leaving U.S.: <br /> 17.TransporterAdmowledgment of Receipt of Materials <br /> ransporter Print yped Name gni re ay ear <br /> ca a-),%- / 0 1?1147 <br /> zd <br /> Transpdltir 2 Pri Wed me / g7�� month bay Ye r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Parfial ReJecti. ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Facifl s Phone: <br /> 18c.Signature of Aflemate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> H141 H141 H141 <br /> 20.Designated Facility Owner or Operator.Certification of recei t of hazardous materials covered by the manifest except as noted in Item 18a <br /> P' ed/TN me SignaX�"x <br /> Month Day Year <br /> EPA Form 870D-22(Rev.3 5 Previous editions are ob late. D FA TO DESTINA N STATE(IF REQUIRED) <br />