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mnminn1nnmmnnn1511m <br /> 0 0 6 7 7 7 7 9 5 S K 6 <br /> Please pent or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number {:n 10 Che 0-119 ip984 1 2.Page M,of 3.gni @"-R0Pffafp7&,0 4.Manifest Tracking Number �( <br /> WASTE MANIFEST 1006777795 SKS <br /> 5.G11VP s Nimp and Maili"drfrAss Generators Site Address(if different than mailing address) <br /> �Ul 1 1 y iF5 <br /> 0 W Lathrop Rd <br /> MANTECA CA 95336-9670 <br /> Generators Phone: �72-555-1 505 <br /> 6.TrrW rl fYorrilgarr cYS?EMS INCU.S.EPA ID Number -F y R 0111100F 12 0� <br /> 7.Transporter 2 Coman Name U.S.EPA ID Number <br /> C-- IN W�, P RS ENUIRONMFNTAi.. -V(-. TNC, MATIO39:2'2250 <br /> B.Designated Facility Name and Site Address C{_FAN HOR!"i RAN JOSE U.S.EPA ID Number <br /> 1.021 RERRYFSSA ROAD <br /> SAN JOSE , CA 95133 <br /> 408--441-096 CAD0513494310 <br /> Faality's Phone <br /> 9a 9b.US.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 r WtNol. <br /> lal NDN—RCRA HAZARDOUS WASTE, SOLID, DN F' 161 <br /> o (A&ARBENT AND OIL}, 'fin' <br /> z 2, <br /> ILL! <br /> r.7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSP SJ 78044650 DR10542 //�� PSG: <br /> 24H EMERGENCY#800-46t3-1760—CH,'SK?TFI--Contract rat3ined by pnerl or7in0fer nev :+.:rti rr i y <br /> on initial transporter to add or substitute additional trans otters on 'r<T1e�If behalf. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am 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 national 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. <br /> rtify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is We. <br /> fferoes PnntedrrI Name Signature Month Day Year <br /> SO 1 rf— iqZ.s <br /> 16.International Shipments <br /> r ❑Import to U.S. ❑Export from IS. Part of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving DS.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> nsp 1 PrintedlTyped Name I ignatme Nh <br /> Month Day Year <br /> Z 2 Printedrrype me a Month Day Year <br /> 9 2< GZaI /S <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> r 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone'. <br /> W l8c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste qel Manavement Method Codes he codes for hazardous waste treatment,disposal,and recycling systems) <br /> o i 2. 3. 4. <br /> 20.Designated Fadli er .Operator.C ificalion of of hazardous materials covered by the manifest exce as noiblOtern IBe <br /> Printed7Typed Name `1 Signat <br /> EPA(F)oun,VV:21411Vre M <br /> Y <br /> . _ „_�P,rV OuSe ti a obsolete. DESIGNATED FACILITY TO EPA's a-M NIFEST SYSTEM <br />