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i <br /> I <br /> Pleas rint type.(Form designed for use on elite(12- ypewriter.) 0 Form Approved OMB No.2050-0039 <br /> p- 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNI ORM HAZARDOUS <br /> WASTE MANIFEST �.: 1 oi7l p N i LW10-74 t3.1449 <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> iNIERSTAIE M11.1t:-i CENTER 626NAVY,DR <br /> P-0.B(m 6l133 qV(X-K)CA a,A 4lt)�1)6 <br /> 6 TOCK f ON,CA Sl6:21713 <br /> Generators Phone:ti(ki•#3+i-+1 i <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Shi0f'4AZ RDIi S+:•�i�41�f'i(� S ('tU�1UGzi64Ut <br /> � 7.Transporter 2 Company Name U.S.EPA ID Number CA <br /> B.Designated Faality Name and Site Address U.S.EPA ID Number <br /> uir"ANCHOCC*kT)f.VA, LL( L'rilj i14ia1kf <br /> 1i&'Swi EFtC1C;KIn). <br /> RAN CW)COMM,CA 4 Y 4 <br /> Facility'sPhone: <br /> i&8b1-DrUtiU <br /> 9a r 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.1Vol. 13.Waste Codes <br /> 1. W"Le Aefosolls.1WwToWe.(asuh nutfixuwadiiirq 1 Lur4{IratfAy},;" 1, 1 210 Pf # 331 <br /> o lN'iI"i ([7001) <br /> I <br /> i <br /> I z 2. <br /> I w <br /> 0 T <br /> 1- <br /> 3 ! <br /> I <br /> 4 <br /> r <br /> I <br /> 14.Special Handling Instructions and Additional Information <br /> OWI-Frift OR752i,ll uK*rdAotIlWO01ft; <br /> ,r�prieit�i'r�Ik�ciiMr�Clvthrg <br /> I • . <br /> r. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and.I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or (if I am a small quantity generator)is true. <br /> Generatorsl(Kferors Print yped Name Signature Month Day Year <br /> fitf d1 f.-+ ,� 1 r. <br /> _J 16.International Shipments <br /> Y ❑Import to U.S. 0 Export from U.S. Port o entryfex& <br /> �- Transporter signature(for exports only): Date leaving U.S.; <br /> W 17.Transporter AcknoWedgment of Receipt of Materials <br /> Transport P' edrryped Name Signature Month Day Year <br /> a <br /> i <br /> Q Transp erg Prin d e Sgnafure Mbnfn Day Year <br /> a <br /> It <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El puanti 0 Type ty yp Q Residue El Partial Rejection Q Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> C] <br /> tai Facility's Phone: <br /> Uj 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI C 1. t } a 2. 3. 4. <br /> i <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> PrintedTypeVame Signature �.,_ Month bay Year <br /> EFA Form 8704 22(Rev:M5) PreviaUs editions are obsolete. <br /> 1 TRANSPORTER'S COPY <br />