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SSL SK SHIjP# 2321228.95 Please print or type. Form Approved.OMB No.2050-0039 1.Generator ID Number 2.Pag 1 of 3. se. 4.Manifest TrackiNber UNIFORM HAZARDOUS CA�42149 �+►ef� gee (�KSWASTE MANIFEST 1007711"038 V ESV S.G nera els a and ding Address Generators Site Address(if different than mailing address) �.ot�z ., S orage Llc - Lodi Station SAN Hwy: 99 Frontage W Y —927a CA 9522 - 81 � �r TT q L! N1 Generators Phone: SEP n 6.TL � ,�a+T + SE ZU EP umber Tx�MIM 7.Transporter 2 Com an Name U.S.EPA ID tuber CLEi RNR'�36 S ENV SVC M. B MADM3222� 8.Designated Facility Name and Site Address Cj;.E �RWRS OF BUTTO W I Lt-OW U.S.EPA ID Number 2590 LQKERN ROAD E�UTTflM�IILL�1 a CA 93206 CAD9M75276 661-762-6M661-762-6MFacility's Phone: ga 9b.U.S.DOT Description(inctuding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes HM and Packing Group(if any)? No. Type Q Wt.Nol. �MNON--RCRA HAZiARDBUS ATE, TP, P 343 DS, (TRIETHYLENE CLYCM), NO* z z ul 14.Special Handling Instructions and Additional Information T81):BL 83901611 LM4294 c9a g � 64110�1rS 24H EMERSENCY#801-468-1760--x-!/SK/TFI-Contract retained by cera ar cone auths�ri y nIn ini#:ial #ratnta curter #,o add or substitute additinnal trel>�s Deters aneneror's behalf. 15. GENERATOR'SlOFFEROWS CERTIFICATION: I hereby dedane thatthe cantents of this consignment are fully and accurately described above by'lw proper shipping name,and are classified,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmeni of Consent. 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 am as II Gty ge Calor)is he. GeneratorsiOPerorsPrini� y� 5`u� tu�:s' h X 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: ? Transporter signature(for exports Only): Date feaving U.S.: IX 17.Transporter Acknowledgment of Receipt of Materials LLI Tra er 1 Printedfr d Name Signator Day Year p Z T nsporler 2 rintedfTyped Name Sign tore Mona pay Year 10A3170 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue Radial Rejection ❑Full Rejection Manifest Reference Number: 18b.Altemate Facility(or Generator) U.S.EPA 1D Number U I Facility's Phone: W 18c.Signature of Altemate Facility(or Generator) Manih Day Year a Z y19.Hazardous,Waste Report Management Method Codes(i,e,,codes for hazardous waste treatment disposal,and recyding systems) L0 1. "" 2. 3 4. / 20.Oesignate i Owner or Operator:Certification of receif hazardous materials covered by the manifest except as noted in Item 18a Prin€edlf d me �� r � Signature Mo Q� EPA .1277) Previniss Pr=itlnnc ora n# n�oFa