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TR <br /> SK elf)1 P 111 1 <br /> Please print or type.(Form designed for use on Ate(I -pitch)typowtiteri) <br /> Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I.GeneralorlDNurober Page lof 3 margenoyResp'onse Phone 4,Mimirest Tracking Number <br /> "61 - <br /> WASTE MANIFEST lv ;jQ I i, -17 1',,- 1 S <br /> 0 0 5 2"56 0 8 0 KS- <br /> 5,Goneralor's Name and Mailing Address ✓ <br /> r3enstalor's SileArldress(if different than mailing address) <br /> A S3 1i ti;it's I rkl <br /> E.i 4 2-7t I t G-1; <br /> 1; <br /> SWRAMENTO C'A <br /> aneratoes Phone: 1)It -444,-i-'5 25 11 <br /> 6.Trans orter 1 Company Namer U.S,EPA ID Number <br /> S E,'I s 1',t 1*..N 1,3,Y 8 TE pi.9x 1 C, <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site AddressU.S.EPA ID Number <br /> GLE'AN 11111RAORP; WIN UX <br /> toN. ROAD <br /> Facility's Phone: <br /> go, 9b.U.S.DOT Description(including Proper SWPIr 0 Name,Hazard Class,ID Number, 10.Centefnars 11.Total 12.UnitHM and Packing Group(if A No. Type Ouantity, wtivol. 13.Waste Codes <br /> NONE, NO {any))))GRA HAZAIMM.-JUS WCAS"W sou'ps, 'Q M F, 2,i" <br /> (711.v'�U INI <br /> jx--:'3 <br /> Al <br /> Uj <br /> 0 <br /> 4. <br /> 14,Special Handling Instructions andAddillonal Informal <br /> on rsl)X619 7 A.15 1 1�3 31 19 3 <br /> HR 'EMERGENCY 41 4W-1760 UM f TV'Q <br /> nwaj :at nv -in p, S` I <br /> 15. GENERATOR'SIOFFERORIS CERTIFICATION:11 her ibydeclare th6tilh000ntents ofdill consIgnat", <br /> n described above by the propsrshippIng namoi and are classified,packaged, <br /> marked and labeled/placarded,and are In all(aspects I i proper condition for transport according to applicable International and national governmental regulations,It export shipment and I am the Primary <br /> Exporter.I certify that the contents of thls.conslgn Mont=form to the loans of the attached EPAAcknowledgment ofConsent, <br /> I codify that the waste minimization statement Idoolfifie(In 40 CFR 262M(a)(if I am a large quantity*9eneiatel)or(b)(III am a small quantity generator)Is true. <br /> 7=1710fferoes Printedtryped NameSignatul Month Day Year <br /> 16.International SFIpmdrito <br /> "El import to vF Expert from u;S� Pod of entry/exit.. <br /> Transporter signature(for exports only): I Data leaving U.S,: <br /> 17.TransporterAcknoMedgment of Receipt otMaledals I <br /> Transpo a Pants yped Name SignalufsMonth Day Year <br /> 0 <br /> t <br /> 'i <br /> Traniol-Wr 2 P?rhtedfrb6d N Wb Signatum, lionth Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space I Quantity: F]❑Type ❑Residue ❑Partial Rojeollor, u FII eJe9tion; <br /> Manifest Reference Number: <br /> 18b,Allemate Facility(or Generator) U3,EPA 10 Number <br /> Facility Phone: <br /> LU 18c,Signature of Alternate Facility(or Generator) 7 onth Day Year <br /> 19.Hazardous Waste Report Management Method Cod s(Le.,codes forhazardous waste treatment,disposal,and recycling systems) <br /> 2, 3. d. <br /> 20.Designated Facility Owner or Operator.,Certification�f rat alpt of hazardous materials covered by the manifest except as noted)n Item 118a <br /> P(Inte,dr-ryped Nam. Signature Month Day Year <br /> J <br /> EPA Form 1 87.0.0-12,2, (Rev.3-05) Previous editions are�bso eta. GENERATOR'S INITIAL COPY <br />