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z <br />Please print or tore. (Form desioned for use on este (12 -Ditch) tvpewriter.l <br />Fnrm Annmvad OMR Ain 9AArLAagQ <br />A f=orm 6700-22 (Kev. 3-U5) Previous eatuons are oDsolete. GENERATOR'S INMAL GWY <br />'r. <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />CALiWAM%I@ <br />2 Page 1 of <br />3. Emergency Response Phone <br />16.31#-V� <br />(fest Tracking Numberr <br />1,017145320 <br />WASTE MANIFEST <br />Jti <br />5, Generator's Name and Mailing Address Glarmalor'e Site Address (If different than mailing address) <br />I31:3R�`Tt."CM K:.:SEtit ff�1. 8'1�4C.'.Y f :• i ! -'fit :, '; �r ; , <br />law IWIDLISTRiAL. F30. <br />�TrX;1470h1, CA. ��^19 <br />Generator's PharigV,470A,177 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />• <br />P,4rWS ET -P f4. _44TAL 9MXZa SIC <br />7. Transporter Company Name U.S. EPA ID Number <br />6. Designated FaciNy Name and Site Address PA % &Nqf0NI&WAL S0M1XLxS ftU.S. EPA ID Number <br />Isis C ! KID. �E7rld4OtA°t'�a <br />WEST CA %M$ <br />FaWsPhoneplfl-Wf-97V <br />O <br />.gb U.S. DOT Description (ndudirg Proper Shipping Name, Hazard Class, ID Number, <br />10..Contelnem <br />11. Total <br />1I Udt <br />13. y,�,Co. <br />No. <br />Type <br />� <br />andPeddngGroup(Kany)) <br />Quantity <br />Wtifrb(. <br />1. PLCtat! FCPA tb►.Talde# t-A)a WAs"m WAID (CIL, Demm <br />001 <br />I31yT <br />•�"` <br />p : <br />u• <br />3. <br />r= <br />T4: Special Handling IneWctions and Additional Informationi- <br />�'t�i�f]rtt„� <br />LES_ CL1MT��.C,TL"rit; F>A� t:AltiliR��rl�R1Ta1. .r } ;. <br />ti>+ 40-4P'9 1AF1Ot.fi-ki Fifa TRAM-0 -0 APS tJ&e A±PRC�e.V PlPt <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contends of this consignment are fury and accurately described above by the proper shipping name, and are clesslfled, packege�F <br />marked and labeledlplacarded, and are In all respects in proper condition for transport according to applicable International and national governments[ regulations. If export shipment and I am the Ptmary <br />Exporter, I certify that the contents of this consignment conform to the terns of the attached EPAAcknowiedgment of Consent <br />I ca* that the waste minimization statement Identifed in 40 CFR 262.27(x): (if I am a large quantity generator) or (b) (If I am a small quantity generator) is true. - <br />.tsenarata slOfferors PrktedfTyped Name Signature <br />5 e <br />•` ,. ,. <br />J6. <br />F- <br />International Shipments <br />1El <br />to U.S. ❑ Export from U.S.- PortofBrtlyfeldt . <br />Z <br />: Transporter signature (for exports only) Date leaving 'US- <br />0-' <br />17. Transporter Acimowledgment of Receipt of Materials <br />Ttansporferi Pdnted/T S ra MonthDay <br />tN�114` <br />ca <br />Transporter 2 Ptnti d/Typed Nome lure Marik .:. Year <br />18. Discrepancy "• <br />189.0knipan4y IndicaioA Space ❑ S ❑Type ❑ Residue❑ ' PartielReJectlon .❑Fir14RBJ�bIt�._ <br />Manifest Reference Number. <br />18b. Alternate Facility (or Gerwelor) U.S. EPA ID Number <br />s <br />Cl <br />ua. <br />Factllys Phone: ., . <br />U11 <br />18c. Signature ofAltemate Facility (or Generator T�01)ay <br />a1g. <br />Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systema) <br />G <br />1. <br />2 <br />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 1 as <br />PdnWffyped Name Signature Month Day Year' <br />A f=orm 6700-22 (Kev. 3-U5) Previous eatuons are oDsolete. GENERATOR'S INMAL GWY <br />'r. <br />