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�w <br /> C (� 0,1 S 7�? ' FomtApproved.Of,18No.205c.ces� <br /> Please prin� !ortype•(Forth designed for use on elite 12•p:1ch� Fevrrter.) , <br /> I.Generator�IPN'urnher 2.Fage 1 of 3.Emergarcy 7tespense PMne d.Manifest Tracking Number <br /> UNIFORM HAZARDOUS011821828 JJ41FEST fes.};$ <br /> 5. <br /> Cenera <br /> (,,enerator's Name and Slaflin Address <br /> rs S;te Ad2ress(if dtOerent than maiug addres <br /> SAORWEN 7O <br /> neral es Ta <br /> Pt�rte: <br /> JTie�SrC3 " +"' <br /> 8.Transporiar 1 Company nto U.S.EPA IO Number <br /> A. BURY EN VFIDN dEITIAL r_R`!CES !; 3 L;�7!'t U +, <br /> 7.Transporter 2 Company Name <br /> U.S.EPA IU Number <br /> 8.Cosgnatad Fawity Rune and Site Address -- U.S.EPA 10 Number <br /> DK DIXON <br /> 7300CHEYPOIN WAY <br /> DIXON CA 960320 C,AT0to00121302 <br /> Fakir/'s PhON: (70—7) 93-8008 <br /> 92. 9b.U.S.COT Description(Including Proper Wpong Namo,Hazard Class,10 Number, 10,Coctainers 11.Total 12.Unit 13,'A'aste Codes <br /> fl,yt arid Packing Group(if any)) No. Type Cuaefty TA.M. <br /> tr <br /> 1-NON-R(3RA HAZARDOUS VfASTk,LI'uici (OILY WATER) 001 TT Iii 223 <br /> z. <br /> HEGEVEED <br /> 3. 0C.T 0 6 2014 <br /> f <br /> MENTAL HEALTH <br /> 4. , <br /> DEPARTMENT ! <br /> W.Special HandSng Inskudions and Add tend Infcrmatien <br /> NAE rlG# 9 B i: 171 u P R 0 F 1 L E#9Li:0K100127 Ef0ER(3EN C Y C0N-1ACT:C Hs;3rC:f—M 04 2 4--9 30 r" <br /> AEt7ITi0iJAL EIDA CODES : 9B:1-, i40NE*APPROPRIATE PERSONAL P,ROTECTIYE ECQUII'i,ENT <br /> ib. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby doeve that the contents of his consignment are fully and iiauralely descnted above by Ole proper stuppng name,and are classfed,paccaged, <br /> marked and labeled/pracarded,and are in A respects!n proper condition fcr transport according to applicable lnternatcnaland nallwal gc+ammental regulations.if export shipment and i am IN Haw/ <br /> Exporter,I carti(y that the centents of this constgnmentcentcrm to the terms of the attached EPAAcknowiedgment of Consent. <br /> I certity that the waste minimization statement identified:n 40 CFR 262.27(a)(if i am a!arge quantity generator)or( (if I am a_sm' uandry genera:or)Is true, <br /> ?,tomb D y Your <br /> Ger>aLatofslOtterof 5 Ptf tc�'ITypad Name S"9naluro ` t <br /> t 16.International ShipmentsEx rt from U.S. Port of entryte d: <br /> i- ❑Import to U.S. � Pc <br /> Transporter s'gnaturo(for exports only): Date leaving U.S.: <br /> 17.Transporter Adtrxiafedgment cf Rece'pt of MaletiafsLU <br /> _ <br /> Transporter 1 PriniedlTyped Nama S;gnature —�----' bt�nth Day rear <br /> _ �1 c!7 D <br /> y �� S.nature hloaltr Day Year <br /> r4 Transporter 2 Printedlryped Name 9 <br /> I- - <br /> 18.Qiscrepancy ��I <br /> 16a.Discrepancy twication Space , El quantity ❑Typa ❑Residua ❑Partial Relect en LJ Fu!Relectien <br /> ;Manifest Reference NumW-- <br /> 16b.AlternateFaClfiy(of Generalot) <br /> U.S.EPA IO Numter <br /> U <br /> ti Facid b/s Phor a: Yungt Day Year <br /> p i6c.Signa!ore of/dtemate Faclity(cr Genera±ot) <br /> Q <br /> Z <br /> 19.Hazardou-09aste Re art Management kleQted Codes(Le.,codes for hazardous waste treatmeni,disposal,and tec din systems <br /> p t• 2. <br /> 2g.Designated Fac3ity(}hear cr Operator:Certification of receipt of hazardous materials covered by Uro manifest e:ccepl as rtded'n Item i6a <br /> PrinledrTYped Name T- 5!onature- _ Mcnih Dw 'roar <br /> LT8700-?.1.(Rev.3-OS) PreviousediUonsaraobso!gte. D�al�il lfL3 ,�C1i ri vro Q'i5 ix,1C7�1:i1'we(li CII~CUUIaI D) <br />