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-4p lam la3 f4W <br /> A p I ?. " k/ 1 I i,` <br /> Please '`y tIr-We.1lForm designed for use on elite(12-pitch)typewriter) ) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I,Generator ID Number 2.Page 1 of 3.Enargetroy Response Phone 4.Manifejst Tracking Number <br /> WASTE MANIFEST CA fl s K'l S { 725 G B F <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> MA-PRt WOOCUF00GE <br /> 1961W N LOWER FACtgAMEF1#Y3 PE) <br /> Aifn:08PIKWIE.CA xc?h`i <br /> GenerabrsPMrie-..•a-y •:sti <br /> 6.Transporter 1 Coming Name - US.EPA ID Number <br /> $FI()P FAtUs M SOLURONS,INC t;rt n!11+34d4;Fd <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 6,Designated Facility Name and SileAddress <br /> 13EP.4 R/sWKl COROt3t/A,AC U.S.EPA ID Number <br /> t ir;56'Ai#dTE kf}�k C�'.a. t:?sD9608B8#33 <br /> RANCHO C)fd[YNA,CA 957d1 <br /> Faallly's Phone: t7SSj-3,r'11 4x`,1 <br /> 9a. gb US.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> 11.Total 12.Unit <br /> HIM and Packi°g GrauP(if vry)) No. Type Quantity WtNol, 13.Waste Codes <br /> I. W-4R[)O S WAi Si N.O.S.9;Ul43Ur7,i3 1 L7,S4 ?sa P U018 339 <br /> � z i <br /> 3 GEM has the appropric to <br /> permits for, and will acc pt <br /> d. <br /> the waste this generato is <br /> shipping. <br /> Id Special Handling Instructions and Addlianal Information 1 <br /> f'f'OFIME.';F? "�IRhl} en�aCY d�11�12a� 1 �flta�4A't"w3'f't);� '9'.t§t.�i> <br /> APPROPRAfF PROiEONE CL0THINC: <br /> SFE ERG 4171 <br /> 15. GENERATOR'SfOFFEROR'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 paticeped. <br /> marked and IabeleNplacarded.and are in all respells in proper complain for lansporl according to applicable inlernafionaland national gomrnmenlal regulations.If export shilxnent and I am me Primary <br /> Exporter,I certify that the conlenls of this consignment conform to the terms of the attached EPAAckrroMedgment of Consent. <br /> I certify Nat the waste minimization statement identified 41 40 CFR 262.27(a)(if I am a large quantity generacr)or(b)Off am a small quantity generator)is he. <br /> GenealoeslQOprors PnnWfrypW NameSgnaturd <br /> t Month Day Veer <br /> 16.International Shipments p. ❑Imprad to US. ❑Export from USM1 Pon of enlrylexif. <br /> T Tammorler signature(for exports ontyg Dale leaving U.S.: <br /> w 17.Transporter AckrkaMedgmenl of Receipt M Metenals <br /> Fe Tan n!er�l Printed}f/typed Name •� is. Month 0, Year <br /> w 7f' fir 7 ..� ' <br /> Trartipboter7Prififfelffititled Name Signaua an <br /> Day Yea <br /> s <br /> r <br /> i <br /> 18.Discrepancy <br /> 189.Discrepancy Indication SpaceEl <br /> QuantityTypc Residue ❑PaNal Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Faclay(or Geneato0 U.S.EPA IO Number <br /> U <br /> sap. Faritiys Phone, <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> H19.Hazardous Waste Repan Management Method Codes(ie.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. r 2. 3. 4. <br /> i I 1 <br /> 2o.Daagnaled Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as ncsm in Item 18a <br /> Pri. yppd Name v— SgnaWa i Month oaY Yeer <br /> EPA Form 6700 22(Hey; S) Previous editions,are obsolete y. <br /> DEyalGMtlr5' D F^rS:9R.13°!'S COPY <br />