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Please print or type. Form Approved.OMB No.2050-0039 <br /> Generator ID Number <br /> UNIFORM HAZARDOUS 2.Page 1 of 3.Emergency Response Phone 4.Manifest TrackingNmber <br /> WASTE MANIFEST 1 CAL000379505:; i 8775772669 012962758 F L E <br /> 5 Generator's Name and Mailing Address Generator's Site Address(if different than maili19=41013 address "y <br /> , , ` nal #403, Swart 9ina�#403 <br /> 2094643829 147_.N. Wilson Way 147 N. Wilson Way <br /> Generator's Phone: Stockton, CA 95205 Stockton, CA 95205 <br /> 6.Transporter 1 Company Name <br /> U.S.EPA ID,Number <br /> S eric cle Soecialtv Waste Solutions Inc MNS000110924 <br /> 7. �spqer 2 Company U.S.EPA ID Number <br /> r <br /> 8.Designated aciliiy Name and Site Address " 0 Chem, LLC U.S.EPA 10 Number <br /> 425 Isis Avenin <br /> Inglewood, CA 90301 <br /> Facility's Phone: 3237766233 CAP 364432 <br /> 9a. 9b.U.S.DOT Description(including"Proper Stopping Nam(khazard Class,l4 Number„ 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)). 13.Waste Codes <br /> No.. Type Quantity WtJUoI: <br /> ce X 1:UN3264, Waste Corrosive liquid, ac d'ic, ' i DF 00142 1) 791 "1009 <br /> inorganic, n.o,s. (Acetic Acid, Phosphoric <br /> R13#1 <br /> LU "Non RCRA hazardous waste, liquid (Consumer 1 DF 00124 P 331 <br /> Products), <br /> 3-Non RCRA hazardous waste, solid (Consumer 1 DF 00131 P 331 <br /> Products), <br /> _. 4. <br /> 14.Special Handling instructions and Additional,lnfom ation 1."101297(Corrosive Acidic Liquids) x. 101320"("State Re u lat ed ti; <br /> g , <br /> Liquids -CA) 3.1.01321(State Regulated Solids - CA) <br /> 15: GENERATOR'S/OFFFROR'S CERTIFtGA IQN,t hereby deglare that the contents of this consipment are fully and accurately described above by theproper shipping aanje Arad are cassifiekt,p kaged; <br /> marked and labeled1placarded,and are in all respells in proper condition for transport according tp:applioble intemationatand national governmental regulations,ff., p.rtshipmea and.Gam the Primary <br /> Exporter,I car,*that the contents of this consignment conform tg the terms,of the attached EPAAcknowledgrnentot Consent <br /> I certify that the waste minimiadon statement idyn#Win 4l}CFR 262.27(ap(if t am a targe,quantity generat or(b)(tN am a small quantity generator:)is true; <br /> Generators/ rorsPrinted/FypeN Signature D F!_ alt of rt - Z Month Day, YAar <br /> r., 1fiJnte ationalShipments 02 ;, 13 1 <br /> F_ ❑Importto U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date"leaving U.S.: <br /> W 17..TransporterAdmowledgment of Recelptof Materials' <br /> oTransporter 1 Printed/iyped Name Signatures (h. pay" " Year- <br /> a- Kristo her Aleanza 02 <br /> Z Trans` Pnntedff Name <br /> Signature Month- flay l�ae <br /> 1; ,//,[ <br /> 1 . iscrepancy <br /> 18a:Discrepancy Indication Spacet�—} ��'i� <br /> Quantify ❑Type <br /> ❑ LJ Residue. ❑Partial Re' <br /> lediorr � L 1 <br /> FuIGRepn <br /> Manifest ReferenceNumber: <br /> 18b.Alternate Facility(or Generator) U.S.EPAfD Number <br /> TU <br /> - Facilitys Phone: <br /> I.M.LU <br /> Signature of Alternate Facility(or Generator) `~ <br /> Month Day Yep <br /> 19.Hazardo s to Report ManagementMethod Codes(i.e., for hazardous waste treatment••,dsposal,and recycli sy ems) <br /> LU <br /> 3: 'V 4 v <br /> 26. siynated. Shvner or." <br /> 4 <br /> ty: Operator:Ceofica00 of receiptof hazardous materials covered by itse est except in lte 18 <br /> tedlT <br /> ame`" <br /> Signature <br /> QU 22((rev:12-17) Previous�ld+ons ire'obsolete. � a <br /> DESIGNATED AQUITY==.T,4f0-4eVARFAW <br />