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Please print or type (Form designed for use on elite(112-pitch)typewriter.) Form Approved.OMB No.2050-0039
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<br /> UNIFORM HAZARDOUS 1 Ganeratnr ID Number 2.Page 1 of 3.Emergency Response Phone 4. anlfaet Tracking Number
<br /> WASTE MANIFEST CAL 000 2$+46 1 (050 993-9538 JJ K
<br /> 5.Generator's Namfe and Mailing Address ARINE #6 Gerism1oft 8iEaAddress(If dlffafent then mailing address)
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<br /> to i„ :' t, - 1810 FIELD AVE
<br /> � 9W 8 STOCKTON, CA 95203
<br /> Gensratw's Phone: o0g)ug-2g22
<br /> 6,Transporter 1 Campany.."a U.S.EPA ID Number
<br /> 0 INDUSTRIAL SERVICES 10K,435 642 742_
<br /> 7.Transpo or 2 Company Name U.S.EPA ID NunMer
<br /> SMITIA VtTEMS NED 086 382 133
<br /> 9:Designated Facility Name and Site Address U$ 0LOGY,INC U:S.EPA ID+Number-
<br /> HIC3~Y 95, 12 WES SOUTH OF BEATTY NVT 330 010 000
<br /> BEATTY, NV 89003
<br /> Facility's Phone: (7751553-2203
<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 Quantity Wt.Nol.
<br /> X 1'UN1950,Waste Aerosols, Flammable, 2.1 (DOT-SP 11296), 001 Dtvl 00044 V D001 DOM D039
<br /> ERG 0126
<br /> 331
<br /> X "ft4, UN1993,Wade FUMMAble Liquids, n.o.s. (Gasoline, 001 Of 00038 P 331
<br /> Petroleum DIAfte0.3,Pill,ROP001, D11011), ERG#128
<br /> X I"RO,UN3244,erste solids containing corrosive liquid, n.o.s. 001 _ 00015 P PAO2 D008 0011
<br /> (5ulturicAldd,MurialticAcid), 8,PGII.RQ(D011), ERG#154
<br /> 7'92
<br /> 4.Non-WT,Non-RCRAFlarardous 002 DISI 000" P 331 141
<br /> 1.4.Sperinl Handling Inslrucifons and Ad.Ronal Information �
<br /> i :v�_11 A i i i r trt;ul, p Film ; 1NESThi rIcP-?,rr7ob;? !.itltwj, '3,WV;TN', 6' wld tiquwdw 4 IVES0t "'Pa.r_`.1-Fars ,
<br /> WF9TM02L I WESTNX tT 14 4..4,t 1243 'I I
<br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged,
<br /> marked and labeled/placarded.and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary
<br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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 generator)is true.
<br /> Ganeralor'slClfterpr s Fnnte0yped Name slgoalure Month Day Year
<br /> Ado—
<br /> .1 16.In emational Shipments
<br /> H ❑Import to U.S. ❑Export from U.S. Port of antrylaxit:
<br /> Z Transporter signature,(for exports only): Date leaving U.S.:
<br /> 17.Transporter Acknowledgment of Receipt of Materials
<br /> uJ
<br /> Tfanspoder i PrinLedlTyped Name Signature Month Year
<br /> v L .
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<br /> f8 6obirler2 Prinledfryped Name Sign Month Day Year
<br /> 'I B.Discrepancy r�r�
<br /> 188.Discrepancy Indication Spaee r Elgaantlty ❑Type L�Rnsrdub i
<br /> Partial Rejection Full Rejection
<br /> Manifesi Reference Number:
<br /> 18b.Alternate Facdlily(or Ganemtor) U.S EPA ID Number
<br /> U
<br /> ua Facilityrs Phone:
<br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year
<br /> a
<br /> N19.Hazardous Waste Report Matlagnment Method Codes[i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> LU 1. 2. 3, 4
<br /> H141 /�� Ni�3
<br /> 20.Designated Facility Owner or Oporatar-,Certlkcali4n of r Lpf hazardous materials covered by the manifest except as noted in Item 18a
<br /> Prin1,6'f$ ,,d Signature Month Day Year
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<br /> EPA Form fi7DO-?J(Rev.3-0y) Previous editions ere obsolete. DESIGNATED FACILITY TO GENERATOR
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