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ASK V41 P* 22193048 <br /> assigned for useon elite(12-pitch)typewriter,),, Form Approved.OMB No.2060-0639 <br /> 4PO1:GeneratorID Number 2.Pa 1 of 3. m sepp 4.Manifest Number <br /> .NIFEST�B 9 �- L 9, <br /> S 110 E <br /> fs Name and Mailing Address Generator s Site Adtlressif different than mailing'aildress) 1 " <br /> 5 olde." ft <br /> AM WwA Stafiford Rd Att samue,I Mehenry 185-91 Stanford Rd <br /> TRACY:, t:," <br /> CA 95377 Attn Safety Sam <br /> t7 700 <br /> Generator's Pttone:� <br /> sa 4 TRY C 9 <br /> 6.T. !X 2 n ff"'bY' T ES INC U.S.EPA ID NVMber E K <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> r <br /> A <br /> 8.Designated Facility Name and Site Address <br /> SAFETY -EN QF CLI OR I R U.S.EPA ID Number <br /> 6880 SMITH R t <br /> NEWARKCA; 9456 <br /> 5�0-79,5-4400y <br /> Facility's Phone: r <br /> 9a•. 9b,U.S.DOT,Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers . 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.NOI. <br /> �. RCRA WASTE,STS, LIQUID TT I <br /> 0 tuwv OIL) <br /> z 2. " <br /> W <br /> 3. <br /> 4. S, . <br /> 14.Special Handling Instructions and Additional InformationT-S a Eve 1CBS. <br /> 4 R EMER13ENCY #1-6"-4176121 (SK ® T I) <br /> T S " 5 T®FOR" Dy, 8EN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <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,]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 alarge quantity generator)or b)(if I am a'small quantity generator)is true. <br /> Generatoes/Offeror's Printed/Typed ame Signature t m Month, Day'y Year:, <br /> d lit6 7 1 t. <br /> -J 16.Intematiionai Shipments <br /> F— ' ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporiersignature(for exports only): Date leaving U.S.: <br /> w 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1,Printed/Typed Name ignMonth " Day Year <br /> r <br /> za Transpo r 2 Printedffyped Name Signature Month Day Year'. <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑T e <br /> yp F-1 Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number ra <br /> J L S <br /> w Facility's Phone:. <br /> w 18c.Signature ofAiternate Facility(or Generator) Month Day ,,Year; <br /> Q <br /> z i <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment;disposal,and recycling systems) <br /> UJ 1 2• 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered,by the manifest except as nolepXtem 18a' <br /> Printed/Typed me, Signature Month' Day{ Year <br /> EPAo 8700-22 Re .3-05 Previous editi ns are obsolet . <br /> f rt DESIGNATED FACILITY TO GENERATOR <br />