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is <br /> Please print or type. (Form designed for use on elite (12 pitch) typewriter.) " e Form Approved. OMB No. 2050 0039 <br /> 1 . <br /> Generator ID Number 2. Pa t of 3. Esq g1 �s�Pne . 4. Manifest Tracking Number <br /> UNIFORM HAZARDOUS C A L 0 0 0 2 6 4 13 2 t�glJ8 4L 016774117 <br /> (` /y. ^I @ { 19' <br /> WASTE MANIFEST 1 (J 4 1 a�a� Y'C <br /> 5. Generis 141�� IHW' W ss711002 Generators Site Address (if different Than mailing address) - <br /> PO BOX 3191 2714 STAGECOACH <br /> MODESTO CA 95354 <br /> 209943-4730 STOCKTON CA 95215 <br /> Generators Phone: <br /> 6. Trans'AYAWQpOPbNMENTAL SERVICES u3. WDINV�2` 2 2 7 7 0 3 6 <br /> 7. Transporter 2 Company Name U.S. EPA IO Number <br /> 8. DesVdF(ZL1S'8mp.and.SOeAddrgs50 U.S. EPA ID Number <br /> 5375 SOUTH BOYLE AVENUE <br /> LOSANGELES CA 90058 CAD097030993 <br /> Facility's Phone: (323)277-1500 <br /> 9 <br /> 9b. U.S. DOT Description Budin Prager Shipping Name, Hazard Class, ID Number, 10. Containers ' 77, Total .12. Und a p 'on (n g rape p i 13. Waste Codes , <br /> . HM and Packing Group (if any)) No, Type Quantify Wtivol. <br /> il. <br /> NON-RCRA 3 <br /> 52 <br /> o - DM 2 �a P <br /> w <br /> 2' <br /> 3. <br /> 4. <br /> ' k <br /> d <br /> 14. Spedel Handling Instmctons and Additional Information <br /> EMERGENCY CONTACT : CHEMTREC 1-800-0249300 NAERG# 961 : 171 * PROFILE # 9131 : P 205533 OILY SOLIDS-PAPER <br /> FILTERS * P500-00043131 * APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT � ! ^ <br /> 15, -GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper staff name, and are classified, packaged, <br /> marked and laheletl/placarded, and are In all respells in pmpercondition for transport accord to applicable intemafional nd nafionat govemmenlal regulations. If export shipment and I am the Primary Exporter, I small that the contents of this consignment contemn to the terms of the attached EPAAcknoWedgmena of Co cot. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a) (if l am a large casualty geneator) of (b) ' am a small quantity generator) is We. <br /> Gen Iors•OH ss Pan ped If it Signature -- - ' ' Mon�rythy Day Year <br /> 77 16. Imarratona ipmeas ' <br /> H <br /> import to as U.S. ❑ Export from U.S. Port of t <br /> 25 Transporter signature (for exports only): Date leaving U.S.: <br /> w 17. 7radspdde -AckoriWedgmenl of Receipt of Materials <br /> K T . Roden Pried/T ed Name Signature Month Day Year <br /> LAZE v o _ X D g1 L2. I <br /> z Imnspoder2 mirellypert Name SignaWr Month Day - Year . <br /> Ems— t <br /> 18, Discrepancy <br /> 18a. Discrepancy Indication Space Quantity ❑Type ❑ Residue El Partial Rejected ❑ Full Rejection <br /> Manifest Reference Number, r <br /> F 18b, Alternate Fadlity (or Generator) <br /> U.S. EPAID Number p <br /> J <br /> U <br /> Facility's Phone: <br /> m 18c. Signature ofAltemate Facdity (or Generator) Monty Day Year <br /> Q <br /> z <br /> C9 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous wastetreatment, disposal, and recycling systems) <br /> a t. 2. <br /> 20. Designated Facility Ovmer or Operator: Certification of receipt of hazardous materials covered by the manifest except as road in Item 18a <br /> Panledry sit Name Signature Month Day Year <br /> a <br /> EPA Farm 8700-22 (Ree 3-05) Previous editions are obsolete. DES,GNATED FACILITY TO DESTINATION STATE (IF REQUIRED} <br /> E <br />