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Please print or hype (Form designed for use on elite(12-Ditch)typewriter.) �. <br /> �I�I <br /> Form Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS I 1.Generator ID Number 2.Page 1 of 1 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAi1C�L 04276 141 '17,7 5 7 7 2`6 <br /> 010790368 F L E <br /> 5 <br /> 5.Generator s Name and blailing Address Generator's Site Address(if different than mailing address) <br /> Hatlt t?od� iuorks S1 Bat^ BQrwY tivY'Y:5# <br /> -0!1952-4396 5308 PACIFIC AVE. SHERWOOD MAIL/ SPACE G J208 PACIFIC AVE <br /> Genemt.(S PIL.ae: STOCKTON, CA 95207 S T L CKTON, Cts <br /> 6.Transporter 1 Company Name <br /> U.S.EPA ID Number <br /> Steric'ycle Specialty waste Solution; inc sir S0Numb .10-D247.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 1 <br /> g 8.Designated Facility Name and Site Address beneral Envir-onmenral <br /> Mgt, L; U.S.EPA 10 Number <br /> 11855 White Rack Road <br /> Rancho Cordova, CA 95742— Facility's Phone: 9163510980 CAL19B08841$3 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, go, <br /> rs <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> Type Quantity WOVoi. <br /> 1Non RCRA hazardous haste, liquid (Soaps, DF 0015$ P �l <br /> w <br /> Z 2. <br /> UJ <br /> (9 i <br /> i <br /> 3, <br /> ( <br /> 4. 1 <br /> r <br /> 14.Special Handling Instructions and Additional Information <br /> 1. 1109@2(State Regulated Liquids) <br /> 15. G ENERATOR'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, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and rational governmental regulations.If exportshipment 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. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(d I am a small quantity generator)is true. <br /> Generator's/Offerors NntedfTyped Name ignature <br /> a� Br�CL * eP a behalf of �ite on ay ear <br /> --i 16.international Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit: _ <br /> Trans iter si nature for ex orts onl Date leavin U.S.: <br /> w IT TranspoderAcknowledgment of Receipt of Mater als <br /> Transporter 1 PrintedlTyped Name rgnature <br /> 0. on ay ear <br /> Z Transporter 2 Printedlfyped Name ig. ure <br /> 9 Month Day ear <br /> r- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection <br /> J LJ Full Rejection <br /> 18b.Aitemate Facility(or Generator) Manifest Reference Number: <br /> U.S.EPA ID Number <br /> U <br /> a <br /> w Facili s Phone: <br /> W loc.Signature ofAltemate Facility(or Generator) <br /> Z Month Day Year <br /> CD <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> 1' f 2. 3. <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed;Typed Name <br /> Signature Month Day Year <br /> r� � -7 <br /> EPA F@!��22*3-05) Previous editions Are obsolete. `{ °' �Q <br /> DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />