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166 1 <br />Ask - <br />Please print or tvoe. (Form desianed for use on elite (12-nitchl tvnewriter.) <br />? rimv. - Previous et ns are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone76611MD'SKS- <br />t a <br />WASTE MANIFEST <br />1- <br />1 -880-468— 17 <br />5.Generator's Name an Mailing Address Generator's Site Address if different than mailin address) <br />,WESTERN FAAS SVC INC STERN �'RRM SVC IRIC <br />1905 N BROADWAY PO BOX 5188 1755 N BROADWAY ST <br />STOCKTON Cts 95905 PO SOX 5188 <br />Generator's Phonne::N —5 ° —26 ST CKTON CR X 5203 <br />Fi 8�t %YST MS, INC. U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number j <br />r <br />8. Designated Facility Name and Site AddressSAFETY-K N SYSTIE14997 INC® U.S. EPA ID Number <br />600 815TH STREET <br />SACRR NTT CA 95820 <br />916-386-4913 CA� 84517 <br />Facility's Phone: - <br />ga <br />HM <br />9b. U.S. DOT Description (including Proper Shipping Name; Hazard Class, ID Number, <br />and Packing Group (if any)) <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />Quantity <br />Wt.Nol. <br />X <br />'POSTE PAINT RELATEDTERTAL, 3g UN1 63, <br />DM <br />P <br />F083 DOW <br />D018 <br />o <br />! <br />%035w3S <br />Z <br />2. <br />LU <br />0 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information K TRCK# jr1L0fi$43@!,,-,,,P834�26@24 0000369974 0926 24 <br />SK,AU-THORIZED,,TO RETAIN LI <br />15. GENERATOIt1/0EE4ROE'S CERtI ICATtON; I hereby deglare thatthe of'this consignment ment are fullyand accurately described above by -the propeS shipping name, and are classified, packaged, <br />marked and labd4plaoarded, and are in all respects in proper -condition for transport accord!'ngio applicable international and national'govemmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that.the, ntents of this consignment conform to the terms of the.agached EFAAcknowledgmant of Consent. <br />loertily.thlat the W4 Mini mlzation statement Identified in 40 CFR 2(52.27(a) (if I am a large quantity generator) or (b) (if] a small quantity generator) is true. <br />Generator'alOfferoesPdnted/iTyped Name �� - 9 Month Da Yea <br />H <br />16. Internationdl Shipments <br />❑ Importto U.S. 0 Export from U.S. Port of entry/exit: <br />z <br />Trans rtereignat exports only): Date leaving U.S.: <br />7. Transporter Acknowledg ent of Receipt of Materials <br />z <br />Transporter 1 Printedff Name ignatur Month Da Ye aL <br />a <br />Trans rinte IT p d Name "Signature Month Day Year <br />a <br />, <br />1�. D(screp ncy, i! <br />18a. Discrepancy Indication Space Quantityn ❑ Type tJ Residue EJ Partial Rejection ❑ Full Rojection, <br />ri M nifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />J_ <br />U.S. EPA ID Number <br />c.> <br />LL <br />Facility'sPhone: <br />uj <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report: Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />{ 141 <br />2. <br />20. Designated Facility ror Operator: Certification o ipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Nam Signature Month Day Ye <br />? rimv. - Previous et ns are obsolete. DESIGNATED FACILITY TO GENERATOR <br />