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RK SHIP* 5 787 . <br /> Please prim pe.. trri dersigned for use on elite(12 pitch.typewriter.),.;,, � Form Approved.OMB No.2050 0039 <br /> t7 ORM HAzARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Number <br /> WASTE MANIFEST .r, <br /> SKS. <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> A.a= N date DId n Date <br /> 1 West food Atte uel c6� n y 18501 Stanford Rd <br /> TRACY - , A 9537777 fa rt Safoty Ram <br /> Generators Phone: TRACY CA 95377—%7@B <br /> 6.Trans orter 1 Company Name U.S.EPA ID Number <br /> A TY- L Y t <br /> 7.Transporter 2 Company Name U.S.EPA ID Number,' <br /> 8.Designated Facility Noe and Site Address U.S.EPA ID Number <br /> CLEM HARBORS GRASSY MOUNTAIN <br /> 3 MILES ATv 7 MIL T�9 KNOLLS IT�'?1� AIF I�BID <br /> KNOLLS HJT 84083 � <br /> Facilitys Phone:. , <br /> 435-804-89150791 1748 <br /> 9a 9b.U,S.DOT Description(including Proper Shipping Name,Haiard Class,ID Number, 10.Containers 11.Total 12:Unit 13.Waste Codes <br /> HIM and Packing Group(if any)) No. Type Quantity. Wt,Nol., <br /> RRA HAZARDOUS TF SOLID (ABS ENT <br /> AND OW) <br /> w 2 <br /> z <br /> 4, <br /> 14.Special Handling Instructions and Additional Information <br /> HN'E <br /> M G #I—SW-468-1760 W4 SK T IIarc 11. .;i l d t' If' L'.. ... <br /> 15. ':GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the'propershipping name;and are,classified,packaged; <br /> marked and labelediplacarded,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 cedify 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 a large quantity generator)or(b)(if I am a small Cityera is true. <br /> Generator's/Offeror's,Printed/Typed Nam Signature Month Day Year <br /> �6 <br /> ,.+ 6 Intematio al Strrpments <br /> I— ❑Import ib U S ❑Exp6rtfrom U S Portof entry'lextt <br /> 7r'arisetrghetu7e`o'expOdsoniy) a � r , -? Datq leaving us, <br /> u <br /> 17` aiis�bdereknowladgmentofReoerpt:QtMatePals <br /> T '.Month 1 Pnhted/Typed Name r <br /> g, Month Day <br /> Year <br /> '� <br /> Transport 2 Printed(iy ed Na Signature. nth. O ar <br /> ham- <br /> 18.Discrepa cy " <br /> Quantity Type❑ Partial ReJection•18a.Discre ane IndicationS ace Residue . <br /> Full Rejection <br /> Manifest Reference Number:, <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID NumberIV <br /> u. Facilitys Phone: F ' ' <br /> W 18c.Signature.of Alternate Facility(o`r Generator). Month ` Day Year <br /> N 19.Hazardoul Waste Report Management.Method Codes(i.e.,codes for haiardous waste treatment,disposal,and recycling systems) <br /> 2. <br /> 13. <br /> 4. <br /> 20. sig ate Facility ner or Operator: dification of receipt hazardous materials covered by the manifest ce t as.noted i to 18a <br /> Prin kf me , Signatu n Te <br /> EPA F 'r ZQO 2(R 0 ),,Pr6Vi6.s,ediUons ar$obsolete,.- SIGNATED,FACILITY: O G RA OR <br /> 62 <br /> ��:�, <br />