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jos .0 -)- o d 12 92s.-29 <br />Generator acKnowledges treat no material change has occurred either in the characteristics or in the process generating the mateltal. <br />01-- n int - h- Form ADDroved. ON No. 2050-0039 <br />EPA Fo nears !-t3�rtfors'has 1e apip°rvprMee permRbsMArd ill accept tete waste the 4efterator Is shlp9�i ATEO.P'ACI�Y TY��b��T �1 M <br />!:140 <br />UNIFORM HAZARDOUS <br />1. Generator ID Number 3. Emergency Response Phone <br />C A L 0 0 0 4 2 0 0 2 3 (80 483-3719 <br />4. ManHact Tracking Number <br />014694693 F L E <br />WASTE MANIFEST <br />5.9tuMb � ��s�LC Generators $iteAddress ('d different than mailing address) <br />14940 W Highway 12 cwur <br />Lodi, CA 95242 _ �r-rrrr c. <br />Generator's Phone: (20913694041 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Clean Harbors Environmental Services.lnc IMAD039322250 <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 />Clean Harbors San Jase LLC CAD 0 5 9 4 9 4 310 <br />1021 Berrvessa Road <br />Sacs lose, CA 95133 <br />Faality's phone: (4081441-0962 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />M.Nol. <br />1 NA3092. HAZARDOUS WASTE, LIQUID, N.O.S., (GASOLINE, OIL <br />DOiS <br />343 <br />o <br />X <br />AND WATER). 9. PG III <br />t <br />PIt <br />o,D <br />P <br />1 <br />W <br />2. <br />W <br />i <br />3. <br />4, <br />Vftlyml ErLctionsand, iylral�tonmation <br />99 77 SSaail## 7777 <br />�jQ, r <br />93 <br />opttact fetal ti t generator confers agency <br />Iuihority on Initial transporter to ado or sutysiiitrie ad 'ionai irannMers on iieneraliors behalf for purposes of iransporfatlon eficlency,convenlence.or safer <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 Iabeledlplacarded, and are in all respects in proper condition for transport according to applicable iniemationaland national govemmental 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 EPAAcknowledgmeni of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 282.27(a) (if I am a large quantity generator) or (b) (ifl am a small quantity generator n true. <br />Generators/Offerors PdrtedlTyped Name Signature Month Day Year <br />I 4S 10.5 1 zf <br />16. International Shipments <br />❑ Import to U.S. El Exportfrorm U.S. Port of entrylexit: <br />? <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />IL <br />Z <br />Transporter 2 Printedi rypod Name Signature Month Day Year <br />18. Discrepancy <br />1 aa. Discrepancy Indication Space ❑ QuarYity ❑ Type ❑ Residue ❑ Partial Refection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />Facility's Phone: <br />SLjy <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />z <br />19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. <br />2. <br />3. 4. <br />Hi4i <br />20. Designated Facility Owng or Operator: Certification of receipt of hjzardous. materials Dove d by the manifest exce noted in Ite <br />PdnledlTyped Name Signalu Month Day Year <br />r <br />EPA Fo nears !-t3�rtfors'has 1e apip°rvprMee permRbsMArd ill accept tete waste the 4efterator Is shlp9�i ATEO.P'ACI�Y TY��b��T �1 M <br />!:140 <br />