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SSI. SF( 5 l l riff, 225562298 <br /> Please prl raype.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number <br /> FO}�M HAZARDOUS —Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Number � <br /> -WASTE MANIFEST SKS f\t7 <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> 185161 A SA N t St Surd AD St - Solder( Sate <br /> 5 r`d Rd A ;n Samuel eery 18501 Stanford Rd <br /> TRACY 3 CA 95377 Atte Lester Sabo <br /> Generator's'Phone: - ,7 4TRACY <br /> 6.Transporter 1 Company(Jame CA 95377-970 <br /> U.S.EPA ID Number <br /> SAFETY- LF SYSTF I T <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> LEAN 14ARBURS ENVIRONMENTAL SVR INC® <br /> 8.Designated Facility Name and Site Address CLEAN hAORS GRASSY MOUNTAIN U.S.EPA ID Number <br /> MILES RAST9 7 MILES NORTH KNOLLS EXIT 419 OFF 1-60 <br /> KNOLLS T 143 <br /> Facility's Phone: 9 IIT9 1 3 1748 <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)) No. Type Quantity 12.Unit 13.Waste Codes <br /> o ? NON RAHAZARDOUS PASTE SOLIDS ( I ' � 3S <br /> 0 ONO RCRAOHAZARDOUS <br /> AR S S PASTE SOLID (A S RPT <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information > <br /> TSD 768273:62 19 Sff <br /> 24 HR EMEROENCY 1"i2- -465-(7 a (CIS i <br /> 15. E S CERTIFICATION: I hereby declare that the contents cgnment are fully and accurately dribed 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 it7.rgovernmental 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 Consen <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 AVa small qua tty generator)is true. <br /> Ge erator' Offeror's Printed[Typed Name Sin re Month Day Year <br /> Jvat� <br /> -� 16 International Shlpments <br /> r=" ❑(fnport to S' :E]export frorrrU.S. Port of ehtry/exd', ' <br /> < Xransportgr'sigrOhd6(for exports only} ; <br /> Date.leavmg U S, <br /> 'LU_:17 Trar!spo Or Acknov ledgment pf Receipt of Matenais <br /> 144- <br /> Transporter 1 Printed/Typed Name 1 <br /> sSignature Month bay Year <br /> Z Trans iter 2 Pnnted/TYPed Na " <br /> �C Si nature <br /> oMonhh Day Year I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type Residue <br /> ❑Partial Refection Full Rejection <br /> Pte, <br /> f s Manifest Reference Number:_ <br /> 18b.Alternate Facility(or Generator) U.S.EPAID Number <br /> _J - <br /> E3 <br /> Facility's Phone: <br /> H 1$c.Signature ofAiternate Factlity{(or_Generator) <br /> a - -::.k: .rv�,�;:: s v ;< MPOth; Day,-.•• Year .. € <br /> Z. R <br /> w19.Hazardo Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. 2. 3 <br /> 4, <br /> fj <br /> 20%Desig6tell Facililf Owner or Opera(r.Certification of receipt of hazardous materials covered by the manifest except as n in Item 18a :Lme I'll <br /> Pd p2d;ae Signal M t <br /> 205) Previo s editions are.obsolete.. DESIGNATED FACILITY TO GENERATOR <br />