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�-185-oi <br />16 Form Approved. OMB No. 2050.0039 <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />CALOQQ3�'3255 <br />2. Page 1 of <br />3. Emer�ncy Response Phone <br />4. Map1ijfT ki m r C <br />U 7 6 K <br />WASTE MANIFEST <br />1 <br />1--800•-468-1760 <br />5. Generator's Name and Mailing Address Generato�s Site Address rt different than mali ad dress <br />CRiiP PROD�ICTION SHVIC: 8 <br />WESTERN FARMS SVC INC <br />1905 N BROADWAY PCI BOX 5188 1755 N BROADWAY ST <br />STOCKTON ' CA 95205 Pit BOX 5183 <br />209-547-2600 STOCKTON <br />CA 95205 <br />Generators Phone: <br />'iAVT Y—' Am%;YSTEMS, INC U.S. EPA ID Number <br />IXR000030930 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address SAFETY—KLEEN SYSTE Ss INC. 000-160 U.S. EPA ID Number <br />6000 88TH STREET <br />SACRAM9NTO CA 95828 <br />916-386-4913' -CA0000084517 <br />Facilil es Phone: 11 <br />ga. <br />9b. U.S. DOT Description @chid ing Proper Shipping Name, tazard 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 (it any)) <br />Quantity <br />Wt.Nol. <br />X <br />'WASTE PAINT RELATED MATERIAL,3, UN12631 <br />DM <br />P <br />F003 D001 <br />D018 <br />a <br />FS II, Sl <br />3 <br />D035 D039 <br />212 <br />:.; <br />:= <br />12. <br />3. <br />4. <br />10000369976 <br />14. Special Handing Instructions and Additional Information SK TRCKK 11232412 0040700269 1007 24 <br />1)ERGS128 <br />24 HR EMERGENCt 0 800'468•-11 0(SAFE Y --LEEN -- 94138) <br />SK AUTHORIZED TO;.RETAIN LICENSED SUBSEQUENT CARRIERS AS. NECESSARY <br />15. OENERATOR'SfOFFEROR'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 al respects in proper condition for transport according to applicable International and national governmental regulations. It export shipment and 1 am the Primary <br />Exporter, Ice* that the contents of this consignment conform to the terms of the attached EPAAclmewledgment of Consent. <br />— -tf certrfy that Nene waste identified in 40 CFR 26227(x) (if I am a large quantity generator) or (b) (If l am a small quantity generator) is true. <br />GeneratcesfOfferor's Printed/Typed Name Siggatura <br />Month Day . Year <br />C1 <br />1021 69VO4 <br />a 16. Interna' ants <br />❑ Import to U.S. ® Export from U.S. ntryl <br />= Transports re (for exports only): pate leaving U.S.: <br />17. nspdxterAck rnent of Receipt of Materials <br />1 Printedfoped Name >Month <br />Day Year <br />tnsporter <br />= T 2 PffnkRqWed Name Signa— <br />Month Day Year <br />e <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quanthy ❑ Type ❑ Residue ❑ Partial Rejection <br />❑ Ful Rejection <br />Manifest Reference Numbs: <br />18b. Allemate Facility (or Generator) U.S. EPA ID Number <br />J <br />L Facility's Phone: <br />U 18c. Signature ofAltemate Facility (or Generator) <br />Month Day Year <br />19. Hazardous Waste Report Matnagement Method Codes (i.e., codes for hazardous wash treatment, disposal, and recycling systems) <br />1:.. H141 _ <br />t <br />2 �� � <br />a <br />a. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the. manifest except as Item 18a <br />nature <br />r Pn /l "d /�—T7 P77"- 1 <br />Month Day Year <br />'A Fo 06-22 (Rev. 3 }Previous ed' ns are sotete. <br />)0412607 2) 3) 4)' <br />SIGN D FKCtMYTO E ERATOR STAIT (1rF1e0L41FiED) <br />