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Fnrm AnnrnvaA r?MRNn 201,0 M.q <br />rlcdac <br />'-jnnt v kyy, kiwi u, �c�,y, <br />UNIFORM HAZARDOUS <br />c .. .... ...... .... ....... �,.. r.....r vr_....._.., <br />1, Geneiater ID Number .' <br />2. Page 1 of <br />1 3. Emergency Response Phone <br />4. M{annifest Tracking Number <br />L1 a1U r% <br />� j J J K <br />WASTE MANIFEST <br />i .� 1 sa t� i .I. i <br />i <br />-�^ l i i -4� +� <br />'' <br />5.Gonerato(sNameardMalingAddress - GeneraWsSteAdd`essiddifleranld!anmaiingaddress) <br />345 1 CHAR�L. SR WA�. <br />S OCKTON, CA 95206 2.09/ 4644^Q66 <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />ALL PHA3S RN M02ITMENTAL <br />7. Transporter 2 Company Name U S. EPA ID Number <br />teAddU.S EPA ID Number <br />S. DesVated Facliy Name and S'ress <br />EV -f OLNT <br />3MIN.INTELLISBLVD, sVR000 3?432 <br />Facility's Phdrre: 3 VECT.M, 2w 39 i 15 742-&• 4-11.67 <br />9a, <br />gb. U.S. DOT Descrption (irduding Proper Shlpp4 g Name, Hazard Class, ID Number, <br />10. Cortainers <br />11. Total <br />12. l.'rh <br />13.'7Jaste Cones <br />No. <br />Type <br />HM <br />and Paddrlg Group (If any)) <br />Ouarty <br />Svt. Vol. <br />Z <br />Z. <br />tW7 <br />3. <br />4. <br />14. Special Handling Insbuctlom andAddticnal Irfo nation <br />•..:trrr..�: �r<�,� ,t�rJ��.l:.s;�uzc�a�� <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby decare that the contents of this cons gnment are fwy and arcura:ey descrtoed abcve by me oroper sh ppirg lame, and aro classified, packaged, <br />international and national'governnw. tal regulation!. if export sh pmert and I am the Primary <br />marked and labeled/placarded, and are In all respects in proper conditcn for transport according to appGao!e <br />Corsent. / <br />Exporter, I cerfy that the contents of -,vis consignment ccnfcrm to the terms of the attached EPA Acknowledgment of <br />anator) or ;b) (if I am a V64 quartdf)I generator) strue. <br />: certit/ :hat t,`e �"ve minim zation statemenl:dent#ed In 40 CFR 262.27(a) ('f I am a large Toan:iy ger <br />Year <br />S:gnaNre _ !Aent� Day <br />GeneratoesfDNeroes Prntedr-yped Name/ -'" <br />p_ <br />IS. International Shipme' nts — <br />❑ Import to U.S. L Export from U.3. Port <br />z <br />a virg U.S <br />Transporter signave ;for exports ory): ate'eavirg U.S.: <br />rY <br />17, TrnsporlerAc:vcw"edgment of Receipt of Materials <br />Monrh Da'/ Year <br />Tran spotl4r 1 PrntediTyped Name . M Slgnalute <br />i�J/! <br />-, r t •.r r r -` l� ( Ile -, .� .� - _ Mcnth Day Year <br />rersporar 2 Printed/Typed Name ' store <br />K <br />r <br />18. Dsuepaccy _ <br />18a. Ctscrepancy ndicaticn Space 0 Cuart y J Tlpe Rcsikh e Par al Ra)ectbn ❑ Futi Resection <br />!'an"ea: Ra`erecce Nucbar <br />J.S. EPA:D Nam2er <br />18b. Alternate =achty for Ganem:or) <br />U <br />tai <br />Faday'sPhona: Month Day Year <br />W <br />1do.Sigrall.f90fAi:ema:e aci:iy;c'Ganara'vr) <br />Q <br />Z <br />19. Hazardcus'Na" Repo2'.1are,errert Method Codes (i.e.. oodes'or h3z-ardous *Wa treatmert d:spcsal..rc rec;:d rg s.stcros) <br />4. <br />n <br />20. Casigna!ed Eap ii y },vner .:r , peratnr Cera) ca8on of receipt of iazardous materafs covered ny ire marded except of naffed in '.8a r/ <br />moral Jay Year <br />PnrreNTy Nanta J } S'gnahue f <br />is ,'fort , <br />` Ifr r .ter, x errr rT..rri r_CU�aeTnR <br />EPA Form 67CQ-ZZ (HSV. U-tp) YrOVIOU3 eUmU75 dke vwwcicf ), t - ..�..•.•• •� • -- • - ----- - - - - -- <br />