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017468179JJK <br /> Please print or type.(Farm designed for use on elite(12-pitch)typewriter.) <br /> 1.Generator Ip Number Forth Approved,OMB No.2060-0039 <br /> UNIFORM HAZARDOUS 2.Page 1 of 3.Emergency Response Phone 4.iNanifast <br /> WASTE MANIFEST CAL 0 0 0 3 9 01 2 3 1 (8W)424-9300 Tracking Humber <br /> p7A6-8 17 9 JJ K <br /> 5 <br /> �� � � UT027 Genar"s Site Address(if Wit rent tlurn mailing address) <br /> 3077 E HAMMER LANE <br /> STOCKTON CA 95212 <br /> Generators Phone: 209 9553162 <br /> 6_Trail 1 INOPIMENTAL sERVICES .8 2 7 7 0 36 <br /> r.Transporter 2 company New <br /> U.S.EPA l D Number <br /> y��IrIC 11.5.EPq ID Nwnber <br /> 5375 3Dll'PFf B4YLE AVENUE <br /> LOS ANGELES CA 900rrg <br /> Facidys Phore: (323)277-15W C AI?0 9 7 0 3 0 9 9 3 <br /> S& 96. <br /> 9U.S.DOT Description(kH*ding proper SNpping Name,Hazard Gass.ID Number, <br /> HM and Paddng Group(d any)) 10.Containers 11.Total 12.Unit <br /> ,.IX NON-RCwa w�zAR�ous WASTE.saLiu(OILY sono.PAPER Ftr�y No. Type Quantity 1N AU 13.Pyrite Codes <br /> 352 <br /> z DM A <br /> 2. <br /> c� <br /> 3LU . <br /> d. <br /> 14.Special Handl ng Irubuctions and Add'tipnal Mfprmalion rr�� <br /> EMERGENCY CONTACT:CHEMTREC 14800.424-9300 *PROFJLE#k 9B1:062'217-p 41L 50U0,PAPER FILTERS <br /> P50000035US*APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT 1 <br /> 15. GEN ERATQR'SIOFFEROR'S C@RTIF1CATtDH: ! <br /> marked and iabaledl Y declare that the carrtants of this oorrsignment are fully and accurately dearrbed above by the proper ship rig name,and are cla-If lad,packaged, <br /> Wacanded,and rre n ak respects in Proper oonditlor for transport according to applicable intemational and national <br /> Exporter,I certify That the c0nWrAs of flits consignment cgNorm 10 the uAcknowledgment urns of the attached EPA govemmenfel regulatlans.If export shipment and I am the Primary <br /> J certify thal tha waste minimization statement ider(tifaed in 44 CFR 262.27(a)( r�Quantity 9eoW i am a la generator) <br /> or @f(b Consent <br /> Generamrs�s pr;nledrf )(i1I am a small gaant 1y gerrarat«)is true, <br /> signature Manu, Day Year <br /> rJ16.lntamational Shhiprm r117 <br /> F- ❑Import m U& <br /> ? rransporkr signaMe{ rxperts onty): E"F°I � <br /> W 17.TransporrerAdrnomedgrneM of Receipt of Materiels "n <br /> Tran�r 1 me <br /> Pdnledlfypad Name. <br /> f.� Sig Month Day Year <br /> Q Transportier 2 Prubdill Name <br /> ah¢e Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indira0on Space <br /> ❑ Qua,tiiy ❑Type ❑Residue ❑Partial Rrt ct. ❑Full Rejection <br /> 18b,Atlsntate Facility{w Generator) Manliest fieferenee Ntxnben <br /> 11.5.EPA ID Number <br /> 0 <br /> 4 <br /> LL Faclily's Phone: <br /> 10 18c.Signature of Akernale Facility{or Garrerator) <br /> H <br /> Month Day y- <br /> 19-Hazardous Waste Report Management Mrs7wd Codas{i.e.,codes for hazarclous waste treahnent,disposal,and n systems) <br /> G t � 1 � � 2 �Yci 9 <br /> �. 3. 4. <br /> 29.Designated Faa dy Owner or Operate Certification of rncaipt of hazardous materials covered by the manirest except os ncted n Item 18e <br /> Printed7l'yped Name <br /> Signature <br /> M;� <br /> EPA Form 870o 22(Rev.345) Previouseitions are obso ete. <br /> DESIGNATED FACI TO DESTINA710N STATE(IF REWIRED) <br />