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Please print or pe. Form designed for use on elite (12-pitchl ty ewriter <br />DESIGNATED FACILITY'S COPY <br />p <br />UNIFORM HAZARDOUS 1 Generator ID Number 2. Page 1 Form Approved. OMB No. 20500039 <br />of 3. Emergency Response Phone 4. Man)feat Tracking Number <br />WASTE MANIFEST 723326 JJ K <br />5. Generator's Name -and MaifingAdores s Generators Site Address (if different than mailing address) <br />F1�1f7t~Ti'tEt:!�'rCc::�rtt;.ly;'t:i? ?7i;r�•:'�"R'! i�Pif34ft!'1'f:!hIG i.�G <br />1.3:0 ltyitlU:� t ti'rr•,L tali <br />TC -C ll, X.1, CA +_r,X6 <br />Generators Phone;,-�-,.•.. ,: <br />6. Transporter 1 Company Name <br />US. EPA ID Number <br />R,z'J'.iCr:� ✓wit�Jr(tZfkiUi+�lEtdT•�3.^y b':,'iCEs fii4 <br />7. Transporter 2 Company Name Gr\O`t7#.;tl''1.,.t,U.S. <br />EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />IA1il1JT¢i'is<rEA. <br />'-VEST SACRAA1EPM), CA 9rla"9t <br />Fad sPhone:9i6-3715747 <br />ga, <br />9b. U.S. DOT Description (inclumng Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />t <br />HM <br />and PacWrg Group (if any)) <br />Quantity <br />WLNni <br />13. Waste Codes <br />No. <br />Type <br />0 <br />1 N(.)N Ft%itM.:,:STP: £3t7LID (Ct!l. DE'_OP131 <br />Ctl3 <br />C7' t <br />"' <br />f, <br />I <br />:,o <br />Z <br />2. <br />f.lJ <br />i <br />3. <br />MAY 10 2018 <br />- j.. . <br />4. ENVIRONfJENTAL <br />HEALTH DEPARTMENT <br />14. Special Handling Instructions and Additional Information <br />54A <br />ZB-IIPP 0MEWC-500i1'a — EPr0171 <br />fz.R.-CONTRACTCIt': PA&to:,• EP `. �f?CA1�dc,'ITHI <br />J4Af;If1! eRS TRAINED ANO fl Ar hR�n,�r"7 7P s(' <br />1,• <br />15. GENERATOR'SlOFFEROR'S CERTIFICATION, i hereby declare that the contents of the consignment are fuly and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeledlo acarded, and are in all respects in proper condition for transport according to applicable intematfonal and national govemmentai regulations. If export shipment and I am the Primary <br />Eocrler, I certify that the contents of this consignment conform to the terms of the attached EPA AdTc Aedgment of Consent <br />I certify that the waste minimtzatlon statement identil In 4D CFR 262.27(a) (if I am a large quanUty generator) or (b) (f I am a small quantity, generator) is true, <br />GaneratorslOffeWs.Prfnte0ypedName Signature Month Day Year <br />r J� <br />r <br />F- <br />16. Intamational Shipments ❑ <br />Import to U.S ❑ <br />z <br />Export from U.S. Port of enlrylexit <br />Transporter signature (for exports only): Date leaving U.S.: <br />ce <br />17. TransporterAoknwAeaterials <br />dgment of Receipt of M <br />Transporter f Printed/Tad Name�j Signature j Mqgih Day Year <br />1 117 1 <br />z <br />a <br />Transporter 2 Priniedyfyped Name Si natu " <br />9 � Month Day Year <br />r- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑Type ❑ Residue ❑Partial Rejection ❑Pull Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) <br />J_ <br />U.S. EPA ID Number <br />v <br />u`l <br />Facility's Phone: <br />W <br />18c. Signature of Altemate Facility (or Generator) Month Day Year <br />a <br />Z <br />H19. <br />Hazardous Waste Report Management Method Codes (1.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />12. n 4. <br />�ILI� <br />�fl. Designated Faiirlily Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as Wed in Item 18a <br />PrinledlTyped Name Signature Month Day Year <br />�> 1 c:• `: <br />EPAFoim <br />it <br />87t70a2 fRev s.nrt o.��,,,� e,�nr.,..� ,.... ,.�...,...._ <br />DESIGNATED FACILITY'S COPY <br />