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Please print or type . (Form designed for use an elite (12-pitch) typowrifer. i . Genemlor ID Numbor __ Form Approved, OMB No. 2090.0039 UNIFORM HAZARDOUS 2, Patio 1 of3, Emergency espouse Pfiono 4. hianlfost Yrackfng Number WASTE MANIFEST CALUU03127$ —^ 1 I I $pf]••f>2�4 9136 p 1Ff 6. Generator's Namo and Malting Addresspp�JGenaralor'sS(IeAddress (Itdifferentthanmailingaddress) JJK 376 11 TH h1t A7 A 704$, DEIRDRE ME]NA MOKE UMNE RIVER FISH HATCHERY CA DFW: 25800 N MCIpmRE RD OA 11TH ST PAS 7CtA CL 1114TS CA-9.5227 OAKLAND CA 9dR07 d I Generator's Phone: v�102871959 6. Transporter 1 Co�m�panyy Nome PATRIOT ENVIRONMENTAL tSERVICES ,S. EPA ID Number t CA0053 MG794 7. Transporter 2�Company Namo "�^ �' " - " — a -.-www. U.S. EPA ID Nwnber 8. Dos gnale Facility Name and Site Address CROSBY At OVER ON U,S, EPA iD WN umbar war 17 TH STREET CAP02640019 II $EACH CA 90813 Facility's Phone: Bt3t1 B27�6729 ga, 9b. U,S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, ,�_,•, 10, Containers HM and Packing Group (if any)) ti . Total 12. Unit t3. Waste Codes I No, Typo Quantity whNol 001 ,)A1 2CJ ' s �. . .. . .. .. . X 21 l ) 4. w 14. 4ecialHan ling nstruOlonsand Addilfonal nformafion ,:p. ~— t, APpPOIKA ► Boa 1B- as '� , E ) C.:.�� ;' G rad } 1 " ib, GENSR1if0R'S10rFGR0R% CMtIFICATfDN: I hereby declare that the contents of this consignmont aro fully end accumiely described above by Ute proper eNpping Hama, aril are dassigod,packed, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable fniemallonal and national gavemmemfai regulations, If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgmenl of Consent I carAfy that the WI minimiza ion statement identified in 40 CFR 262.27(a) (if I am a largo quantity generator) or(b) (If,t small quant) enprator) Is uuo, Ganem srOHeror's PrtRled/Typed Name . —~� Signaler . Mutt i Y + + 8, Intem ahonal Shipments f��Tt '��'"' �"•""""""-'�� ~--�-�- � LJ import to U.S. ❑ Export from U.S, Pori df entry/exit: Transporlarsignalure (for exports only): _ Dale leaving U,S,; 17, Transporter Acknowledgmunt of Receipt of Materials M Transporter 1 Prinledyljpad Name SignatIII ure Month 6-7it"IYear Tronspo er 2 Pdnted/typed Namo Signature Monti my Year 18, Discrepancy - — _ 18a. Discrepancy Indication Space Ll Quantity ( . Type El Residue ❑ PanfalRejection �El Full Rgeogon L Mnifest Ref rants Number. 10b. Aitemate Facility (or Genoralor) +� - - _ "" 7 U.S. EPA ID Number Laft Cllily's Phone; 18 15c. Sfgnalum of Allernale (or Gonernior) Month ( Day Ycar s� 10. Hazardous Waste Report Management MethodCodes (i.a., codes for hazardous waste treatment, disposal, and recycling systems) ` •f�-� �� ° _ _ 3. 20. Designated Facility O Ener or Operator: Certification of recr. r f haznrdo t� lariats coveted by the manliest except as noted In item 185 dnle�/P� r ,l Jam -� e EPA Form [3700.22 (Rev. 3-05) Previous editions are obsolalo , _�.�._� �. ._ � . _ ( y • .;i �zl��,"f3tf �- }.:;i�'c),.tT's` '3'(1 �JtiIT'iPd,�i'f't ,.IPJ xT�flr f1^ 3�t;rC�#d1ElE«ft}