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OCT. 2. 2009 2:23PM IT+LISION DIVISION NO. 719 P. 4
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<br /> Please print or type.(Form designed for use,on elite 12-pitch svmtter. Form Approved.OMENo.2050-0039
<br /> UNIFORM HAZARDOUS ji,GverglorlDNumbor 2.Pagelof 3.Emargenoy ResponsePhone a,Manifest Tracking Number //'++ pp
<br /> WASTE MANIFEST f;gYYap y,Ip�11�s5;I 7 In%).MA .'AAS U U F
<br /> 5.Generales Name end Malin®Addiess Generators She Address(If different then mating address)
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<br /> I' s 5Ri10116.11 tcft,sfT�Yt+ti,a.,y,1,ta'I?nkr
<br /> Gereraloes Phone.Ai-x K4?4 ,1
<br /> 8.Transporter t Company Name U.S.EPA ID Number
<br /> :.f 1 11x 4f L•."1i(%If:b'.ii M l7iICaIJB).Sf M i. FUlfif}16j Jsw1 l!
<br /> 7.Trenaponar 2 Company Name U.B.EPA ID Number
<br /> 8.Designated Facility Name and Site Address d:K•P�fa4iM1K.1•W�Lt�dtf?alliA•Ii<t., U.S.EPA ID Number
<br /> 110544 u147 TE Rf)C,V.EM "�WI F21mrl4t$t Isl a
<br /> ('aA!pli flt.ps;4?FfC#�U.� x,'aynl'A1
<br /> Fadi Phone: rfl4f:.li'nT ei;.kpy
<br /> 99. 9b.US,DOTDesalphon Qndufing Proper Shipping Name,HmatdClaes,ID Number, to.ContalnM 11,Toll 12.unit tg,Waste Codas
<br /> HM and pecking Group Of any)) ,see. Type Quantity MIMI
<br /> QdFEiYA; 11k ::rs.;i olffiMc. :{1t.i18 '! T.dvl 'Jr£A Ce .d'„s'4 K41"
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<br /> 14.Spe4HI'l r•wIRnsfh•Iu.'oAdotns1 a
<br /> nd Addltonat Imolmaion
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<br /> 15, GENERATOR-00OFFEROR'S CERTIFICATION; I hereby declare that is contents or this consignment are idly and accurately dwilbed above by the proper shipping name,and are dasalfled,packegaa,
<br /> marked and labeledlplacarded,and are In an respects in proper Mohan for transport according to applicable iniamationaland national governmental regulations.If export shlpmentand I sm the Primary
<br /> Exporter,I cerilfy that the contents of this consignment conform to the terms of the attached EPAAdmowledgmant or CenwL
<br /> I cerilly that Bre waste mldmizaliol ssremantidemMed In 40 CFR 28227(a)(If I am a large quen8ry gars rater)or 0)Of I amts small quantity gars retor)is we,
<br /> Generatofs/Offerors Printed/Typed Name Siglmlure w. Month Day Year
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<br /> J 15,Int maknal Npmern
<br /> F ❑Impart to U.S. ❑Export rrorn U.S. •Port nbylsdb
<br /> a Transporter signature(ror exports on : Dale lseving U.S.:
<br /> 17.TransporterAcknovtedgmenl of Receipt of Materials
<br /> Treneporlanl PnnnadfType�tly,, ma n Signature ,q` ,t( _ Month Day Year
<br /> 1rerapodar2 P111116aflyped Name Signature Month Day Year
<br /> T18,Discrepancy
<br /> 183.D eaepanoy indication 8pace ❑ Quanlily El Type ❑Residua ❑Farrel Re)ec8on L2 Full Rejecion
<br /> Manifest ferenx urrber:
<br /> 18b,Alternate Fac1ty(or Generator) U.S.EPA ID Number
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<br /> sea. Faclll a Phone:
<br /> Bs. gnawre otAllemale Facility(or Generator) Monro
<br /> Day Year
<br /> 19,Hazardous Waste Report Management Method Codes Qtr„codes!or hamMous waste treatment,disposal,and recycling systema)
<br /> 1, 2, a, Notice:New federal form. State of
<br /> California requires generator to photocopy
<br /> 28,Designated Faclllty Owner or Operator,Carbrication of recelptofhazardous materials c rrered by the nwifeat except as noted In Item 189 and mail to DTSC within 30 days:
<br /> PomaNTypatl Name signature P.O.Box 400, Sacramento,CA 95812-0400
<br /> EPA Form 5700-22(Rev.305) Previous editions are obsolete,
<br /> GENERATOR'S INITIAL COPY
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