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Please print or type. (Form (1664 fled form on elite I2•pilch) ewrltar. <br /> - --- ")[IL Form Approved. OMB No. 2050.0039 <br /> FUNIFORM HAZARDOUS 1 ' s �ralor lD Niunhar �� 2. Pogo 1 of 3. Emergency Rogponea Ptgne �' . esracngmbASTE MANIFEST CAL000431278 (� /� "7 /�nrraI esNameandMaili Addiass _ _ .__. . _. .. . _ _ —..,__�. . ... " 18 ` t 1 4enerators Site hdrass(if df(¢r¢nl than maitinp address) J �f �C51BAY S704DEIRDRI MENA MOKELUMNE RIVER t7uH HATCHERY CA DFW: 25000 N MCIN17RE RDS17TH ST iNS 704KLAND CA 94607 CLEMENTS CA-95227 <br /> Genneratoes Phone; p� 5102871559 <br /> 6• P�aT[ asi f�IS{���2nC NRUTAL SERVICES <br /> ' U.S,EFA ID Number <br /> CAD053866794 <br /> 7. Transponer ? CompanyNamo . <br /> �y I U .S. EPA ID Nvmber <br /> B.CRCgS Y Rradv ft e apd SBaAddress_._ <br /> U.S. EPA IDNumber <br /> 1830 WEST 17 TH STREET CAD028409019 <br /> LONG BEACH CA 00813 <br /> Fadilly's Phone: 80(J-027^6729 <br /> 9a. 96. U.S. DOT Descdplran (ncl6ding Proper Shipping Name, Hazard Class, ID Number, T id. Containers <br /> HM and Packing Group (Irony)) _ _ 11 . Total �~ 12. Unit 13. Waste Codes <br /> -Type Quantity WI.Nd. <br /> u _ i v � I) �/� t3 { nc G <br /> � ►ti121 <br /> i <br /> 3. <br /> a. <br /> 14. Sppe�ci��al Hardin lnstrtdonsendAddlllOnal <br /> WEAR APPROPRIATE PPE JOB #08-10- 00 <br /> 15. GENERATOR'SIOFFEROR'S CERTIPICATION ; I horabydadare that the Contents of this consignmont are fully and accurately describod abovo by the propersNpphg <br /> marked and lalmied/piacarded, and are In all respects in proper condition for transport according name, and are dass�ed, p ckegetl, <br /> Exporter I certify that Ore contents of this consignment conform to the terms of the attached b applicable lnfarnal onaiarx) national regulations, If export shipment and t am the primaryEPAAcknowledgment of Consent. <br /> I certify that the waste mlydmization statement identified In 40 CFR 262.27(x) (if I am a large quantdy goneralor) or (b) (irI am a small quantity generator) is We, <br /> Generalvs/OsoroesPdnled/T oodNoma Signature --- <br /> � , J�) I (� Cs r / iY Year <br /> TL <br /> Una ; UI_. .I Impact to U.S, ❑ Export from U.S. Port of enirylexh:rsgnature (to, exportsonly): DaloleavNgrterAcknarledgmentotReraiptofMete a;s �'- "'-"Iprinted <ypodNama <br /> dr Month Fay Year <br /> Transporter 2PdntedffypodNam Signature ' - - " <br /> ( Month Day Year <br /> 18. Discrepancy (F--t1 -•1� _.— _._ _ 1 _ <br /> S8a. Discrepancy Indication space EJ El <br /> Quantity Type _ ��1Resirlue <br /> Partniallai Rejection ❑ Full Rejection <br /> 186. A0ornaleF8C1IAY (orZ neralor) � _ �� Manifest RoforeAw Number: <br /> U-S. EPAIDNvmber <br /> t; <br /> W Fadily's Phone: <br /> 18x1, Sign alure of Ntemato FacBdy (or Cenoratot) -� - - - - -- �.- <br /> z Ih Day Year <br /> (h 19. Hazardous Waste Report Management Method Codes (I.e.) codes for hazardous waste (realmant, disposal, and recycling systems) <br /> 20. DesignatedFep'ti yneror0 ratonCerlL; oFre"c - -- ^ - ' — _ <br /> f>apl of hoz does maledels covered by Sts manifest except as wed in lion, 18a <br /> Printed ped mo i _ _ Srynature _ --- <br /> ( o�nl r � Day year <br /> EPA For 070 • 2 ( ev. 105 Previous editions are obsolete <br /> IW131( , NA101 f ) I •AC(Li I Y ' 10 f7l.a' TIPIA8110KI.. SPTA'1 E (tl '• (1rQ1f111 D) <br />