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SS�m SK SHIP* 232486325 <br /> Pleas print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3. mee�gg� R s nAse Pho1�e 4.Manifest Tracking NumberCAL0 �[ <br /> WASTE MANIFEST 'r4 �rct i ^t3�,�R�i�'"�PCr 100-7769570 <br /> �}� �1I`S <br /> 5.Generator's Name and Mail Address Generator's Site Address(if different than marlin address)( u <br /> AD � ��oMen Bate AD58A •- Golden �2 e <br /> I&vi@l West Stanford Rd Attn ;Sa uer Mchenr y 18501 Stanford Rd <br /> T6 ACYCA 9,9377 Attn Lester Sabo <br /> Generator s Phone: 2 M. 9-3882 TRACY CA 95377-97M <br /> -97M <br /> 6.Tr �pptterd 130 ,` Y I w U.S.EPA ID Number ,R � <br /> 6i� i b <br /> 7.Transporter 2 Company'Name U.S.EPA ID Number <br /> HARBORS ENV SVC INC. MAD 39322850 <br /> 8.Designated Facility Name and Site Address CLEA WAR ORS OF BUT`t" N IL LOW U.S.EPA ID Number <br /> 8500 >n.C1KERN ROA <br /> x. BUTTONWltal.OW 9 CA 93206 <br /> Facility's Phone: <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./Vol. <br /> 1. WONE I C� I t;R HAZARDOUS ►rd' STI � QP 134 ' <br /> 0 L 1QU gS,r ; (DT SPL. EXAUST FLUID), N/A 1'-)o <br /> z 2. <br /> LLJ <br /> 0 <br /> 3' <br /> A <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> T81);8L 8439,4443 RBE 1 8 C G m <br /> H RGENCY -,4681760—CH/St(/T I--Cornu act retained by generator confers aoncy authorlil y <br /> 6'n i- ilial trantporter to add or, substitute additional tratnsporters o nonerayoro 4 bah#elf <br /> 15. GENERATOR'S/OFFEROR'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 net' nal 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. f <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 1 9nnIsdnall quantity generator)is true. <br /> Generator'slQfferoes PrintedTyped Name Signature '' Month Day Year <br /> 16.International Ship.ents ' ^ <br /> F-- �Import(o U.S. ❑Export from U S. Port of entry/exit: <br /> K Transporter signature(for exports only): Date leaving U.S.: <br /> CC w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name q Signature Month yDay ry Year <br /> Tr6sporter2Pdntedfryped game tur :raa Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type El Residue � El Partial Rejection El Full Rejection .vM <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> u- Facility s Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q - <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ 1. 2. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedfTyped Name Signature Month Day Year <br /> EPA Fo r�,8700-,2�Rgv.12-17 Pr vious editions are obsolete. GENERATOR'S INITIAL COPY <br /> t,z ® r ,r <br />