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far, ;��sat^tT irr_at,�a�yr;.: it type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 : :rORMHAZARDOUS 1.Generator ID Number ' 4;AD9t3c?44# :1 1 . I .R'^ '-�ppoAAss-e1oPa 4.Nam etTrackin Number eerr WASTE MANIFEST 011, t6G J 6 C E 11IS.Generator's Name and Mailing Address - Generator's Site Address tit different than mailing address) . Ca l—Titena Shop 10-• Lodi Cw's ,145 E Pine St I....ODI CA 95240-3108 Generators Phone. m 6.Tr`,B+If iY-TT % 9YSTFWms INC: U.S.EPA ID Number URIHAM61P05 7.Transporter 2 Company Name U.S.EPA ID Number CLEAN fiARBDNS ENVIR43154MENTAL, ;svc YNC. 4+1AD0393222Z9.a 6.Designated Facility Name and Site Address CLEANHARBORS OF RC)TTONWIL.LOW U.S.EPA ID Number 215500 1-11'3KEMN ROAD 13UT` ONWIL OW s CO 93 06 F-.4:61-74a'r_'•-C�cl71i� GA'D!9Fl14C�'7"SS':�CS Facility's Phone: go. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers i,.Total 12.Unit Hny))M and Packing Group(if a13.Waste Codes No. Type Quantity Wt.Nmi. NON RCRA NAZARDC)LM WASTE SOLIDS, � DM P 358 o (AW BENT AND t13E_)4 1477W LU f 3 4. �I 14.Special Handling Instructions and Additional Information TCDD 4 BL. 771,2.54 8 C0479558 CSC$A !!! 24 HR EM RSENCY #IL... @ 4413-17Cs0 (CH 15K < TFD ALITLI A5 "ASE:NT=FOR' BY GEN TO RETAIN S_SCe:N3£iD SUB CARRIER AS NECESSARY 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, marked and latimedlplacarded,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 Exporter,l certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmem of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if i am a small quantity generator)is true. eneramrsl0fferors PtintRUTyped Name signature Month Day Year :-t 16.Inter conal Ship encs r- ❑Import to U.S. ❑Expmt from U.S: Poh ,;n I: Transporter signature ifor exports coni. : Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials - - Tra@Shoderl PrintedlLyped Name Sgnature�•i"� /�" Month Day Year. q cE.,.(.`. - iUn.,J:. ti I t. /t,..*I S M;f:'x t ,•.,w.•;2 -„} .-. I I tl...i QTransporter Pintedflyped Name �i - Signature j Month Day Year 18,Discrepancy - ' 16x.Discrepancy Indication Space El Quantity T e ❑Residue ❑Partial Rejection Full Re)ecyon Y YP j ❑ Manifest Reference Number: 16b,Alternate Facility for Generator) - U.S.EPA ID Number - J t+- Facility's Phone: W 1Be.Signature of Alternate Facility for(renerator) - Month- Day Year 4 2 N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) o. 1: 4. 20.Designated Facility War Operator Certification ofracerpt of hxardous materials covered by the manifest except as noted in Item 18a Mon Sig '- PrintedlType Nam nature rte^ t Ye /Day aT') EPA F)o"PaP 'R 6101401 116041 editioNeete obsolete. DESIGNATED FACILITY TO GENERATOR