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Please prim' ' pe.(Form ed for use on elite(12-pitch)4ypewriter.) H Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1;Qeneratory Number 2.Page 1 of 13.Emergency Response Phone 14.Manifest Tracking Number SKS��VASTE MANIFEST )� � t 7 11-810113-469-1760 S(�V <br /> 5.Generator's Name and Mailing Address Generators Site'Address(if different than mailing address) <br /> MESA, ,.- Bolden Sate i golden tate <br /> 1. 511 est t ord Nd Atto Ael Nc a ry 18591 Studd Rd <br /> TRACY CA 955,177 Mitt Safety Sam <br /> Generator's Phone: RIB, -3934 °RACY CA 93377-9708 <br /> 6.Transporter 1 Company NO% U.S.EPA ID Number <br /> 03 T°Y-1{L. N 'SYSTE148 INC <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HRROOM ENVIROMMAL SVC INC. <br /> B.Designated Facility Name and Site Address 7 7 ; P ENN T Li T N �q ;_ :.-. _,_....- ..__ . -U.S;EPA1D-Number-_ <br /> ILNTt� �°'AN � A 9 ° �0 <br /> 11 55 <br /> Facility's Phone: 1EFT <br /> AA �999 A9 ` <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 /> a tN N-RCRA AZARDOU T v SOLID Ate A an <br /> WIL FILTERS) <br /> z 2: <br /> W <br /> C7 <br /> ti <br /> 3: <br /> 4. <br /> U.Special Handling Instructions and Additional Information ff 7 ti <br /> R CMERGENCY #1-800-460-1760 (CH I SK / TF I r <br /> vamEwT-PrIpt, By Mw 3:0 DZICIN S y � V <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by 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 certifyThat the contents of this consignment conform to the terms)l the attached EPAAcknowledgment of Consent. <br /> I certifythat 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 ator)j <br /> GeneratoPslOfferors Printed/Typed Name "' Signature Mdnth" Day 'Year:'' <br /> q.. J <br /> .J16,Intemationill Shipments <br /> r- Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date Ieaving.U.S.: - <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Tra sporter 1 Pnntedfryped Name Signa Month Day Year <br /> awinm <br /> QTransporter2Printe7 yp .Name Signature Month Day Year <br /> xhR-411 1$1? <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication'8pace El Quantityd <br /> ❑Type- El Partial Rejection ��' El Full Rejection <br /> A <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number r <br /> J <br /> LL Facility's Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year, <br /> a <br /> Z x, <br /> U19.Hazardous Waste Report Management Method Codes( i.e.,codes for hazeIrdous waste treatment,disposal,and recycling systems) <br /> LLJ t 2. 3. 4. <br /> 20.Designated Facility owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Na (( Signature Month Day YT <br /> �f /y <br /> EPA Form 871)0-22(Rev..3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> 9—Cu(Q <br />