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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3,Emergency Response Phone 4.Manifest Track[ Number <br /> WASTE MANIFEST CAR000220046 •g. 909-984-9984 0�0�2 3 5 0 2 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> CALIFORNIA HEALTH CARE FACILITY (07557) <br /> 7707 SOUTH AUSTIN ROAD <br /> STOCKTON, CA 95215 <br /> Generators Phone: 209 467-7904 <br /> 6.Transporter)Company Name U.S.EPA ID Number <br /> INDUSTRIAL WASTE UTILIZATION, INC. CAD980585293 <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> 8.Designated Facility 11ime and Site Address U.S.EPA ID Number <br /> CROSBY & OVERTON <br /> 1630 W. 17TH STREET <br /> LONG BEACH CA 90813 <br /> FadiBys Phone: 562-432-5445 CAD028409019 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Ouanlity WLNoi. <br /> 1 UN1950, Aerosols, (non-flammable, (each not 331 <br /> 0 exceeding 1 L capacity)l , 2.2 p __- <br /> z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.Special HandUng Instructions and Additional Information <br /> 1) inhalers-93930; ERG Iii: 126 <br /> yW -C:::> <br /> it. GENERATO 'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper slipping name,and are classified,packaged, <br /> marked and labeledfoacarded,and are in all respects in proper condition for transport according to applicable International and national governmental regulations.If export shipment and I am'Ihe Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity gen -116 11f, <br /> erator)Is Due. <br /> General a ao s nntedffype Name na ure n ay Year <br /> 16.I ernational Shipments <br /> Ir ❑Import to U.S. ❑Export from U.S. Port of entry/exil: <br /> z Transporter sinature for exports onlDate leaving U.S,: <br /> w IT Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Prinled[Typed Name Month Day ear <br /> a IZ (� . /G <br /> Tr sort r 2 PrintediTy lame Lord Monthay Year <br /> �o <br /> 18.Discrepancy <br /> ilia.Discrepancy Indication Space EJ C wntily ElType El Residue ❑Pallial Rejection ❑Full Rejeclion <br /> Manifest Reference Number: <br /> 18b.Alternate Facl81y(or Generator) U.S.EPA ID Number <br /> C) <br /> Facilit s Phone: <br /> W 18c.Signahua of Alternate rarifity(or Generator) Month Day Year <br /> 9.1-1a We s Waste Report Management Me"Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3. 4. <br /> 20.Designated Fadltly jwne or Operator:corgfrcalion of recei of hazardo s materials covered by Ilia manifest except as noted M Item ilia <br /> Pdnledlrype Nam Slgnalure k nth DPIRED) <br /> j <br /> EPA Form 070 - .3.0 ) Prevlous edit) s are obsofele. DESIGNATED FACILITY TO DESTINATION STATE(IF RE <br />