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❑�....�., �.,..�`nr n,nn !F:— 4ncimnarl fnr ilea nn alita 119-nitrhl hmaauritarl /31 Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Pa e 1 of <br />3. Emergency Response Phone <br />. nifest Tracking Number <br />4Ma <br />1 7 6 9 1 2 JJ K <br />WASTE MANIFEST <br />C A D 9 8 2 5 0 8 2 5 1 <br />1 <br />,;,; <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />U4118d GrOCWS Urlifled Drccer'S <br />Atin. Pat Gants Trety, 5200 Stella Sit et 1990 PiccaA Rd. <br />COrrrrlerce CA 90M Stccktm CA 95215 <br />Generator's Phone: 3 2 3 2 6 4- 5 2 4 0 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />A T 0 8 0 0 1 2 8 0 0 <br />Haz Mat Trans, Inc. IC <br />7, Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA 0 Number <br />Sief w S dater T k)4e5 COT. <br />5:375 50um " Ave. <br />Venom CA 913058 <br />t' © r` <br />Facility's Phone: 8M 266-7747 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />�40n-RCRA Hazards Waste SoNd <br />352 { <br />ce. <br />0 <br />(OiUabsftent) <br />�. <br />DM <br />c!CJ <br />- - - <br />f <br />Z <br />c� <br />wREIEWC <br />2. <br />I <br />I <br />3 <br />J 11 <br />U <br />i <br />4. <br />ENVIRONMENTAL <br />HES <br />DEFrM-EI%41I <br />IMF <br />14. Special Handling Instructions and Additional Information "Z3 / -7 p -2 <br />9b.1) Oil/Absorbent Profile# AP168334 q V jarf✓ _ <br />& GOGGLES <br />GLOVES <br />15. GENERATOR'S/OFFEROR'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 (b) (if I am a small quantity generator) is true. <br />Generato sl fferor's Print /Typled Name Signature r Month Day Year <br />9� 01 16/ <br />N e� <br />16. International Shipments <br />❑ Import to U.S. Export from U.S. Port of entry/exit: <br />z <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials —� <br />Trans orter 1 Print (Typed Name Signature / Month DraYear <br />ayy <br />(L <br />AA <br />G/ t� <br />QTransporter <br />2 Printed/Typed Name gnature Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space. ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Altemate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />U- <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />a <br />Z <br />F519. <br />Hazardous W ste Report Management Method Codes (i.e., codes for hazardous waste treatment ;disposal, and recycling systems) <br />QLLI 1 <br />2, <br />3. <br />4. <br />�—A <br />1t <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous mate covered by the manifest except as noted in Item 18a <br />PrintedlTyped Name Signature Month DayYear <br />p i // 1 .-� 7 <br />7-W , <br />