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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 1 ")44i??vE. `-f POW Vy t 6i a Op-1 Form Approved.OMB No.2050-0039 <br /> D 141 NOTM <br /> WASTE ZARD0US 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> E MANIFEST <br /> t._ y�r f,� .. • _ � �� �e- FLE <br /> 5.Generators Name and Mailing Address rdnerato1 Site Address(if different than mailing address) <br /> tetwheArrianit FiEmt#020 <br /> P0 B° � 400 W llalgice Road <br /> is �A tuft:;J,. <br /> Generators Phone:,x r,, .. . :_•, - , r r� , 4j <br /> 6.Transporter 1 Company ame U.S.EPA l Number <br /> +:tr< ' tlar#Ju t fe+ :_nt+:} ooi4fi. <br /> 7.Transporter 2 Company ame U.S.EPA ID Number <br /> FW 1JC <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number# " <br /> ieBn H.atto,5 Wil"higion Lt(: G !4 f�0#4#2 9 8 R <br /> 1-137 Eastienni Wei <br /> Vkn1111114120n,CA 80744 <br /> Fadl s Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(tf any)) 13.ftste Codes <br /> No Type Quantity Wt.Noi. <br /> It <br /> W <br /> z 2. <br /> 0 MCMSE,�Ity}!d ial�IRA Fel 7�RR l �ta-'W�,!(�d�el015.cI ISED f ,+� �.�/� � 221 <br /> OIL). a'a ( Com° N4�'c� Q <br /> 4 <br /> 14.SPecial Handling Instructions and Additional Information <br /> . 3f1�+U! �b7f ,j �j■tet n� 7 � 1 (—A 7 <br /> 'tr ;7 Z. <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 applic&e 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 EPAAcknowledgment 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 /> GeneratorVOfferor's Printed/Typed Name Signature Month Day Year <br /> 16.Interdational Shipments <br /> ❑Import to U.S. ❑Export from U.S. Pon of entrylexit: <br /> Transporter signature for exports oni : Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> 1 7ranspouef 1`FrintedlTyped Name Signature Month Oay Year <br /> a <br /> rn _ <br /> QTransporter2 rintedfTyped Name J Signature Month Dai Y,at <br /> 18.Discrepancy. —`---- - - <br /> 18a.Discrepancy Indication Space <br /> Quantity L-1 Type El Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> H 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> 0 <br /> a <br /> Facilit's Phone; <br /> Lu 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q ' <br /> z <br /> C9 <br /> in 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Lu 1. 2. <br /> 20.Designated Facility Owner or Operator,Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br /> PnntedlTyped Name r Signature ___ Month Day Year <br /> 4 l <br /> EPA Form 8700-2 (Rev. -05) Previous editions ar obsolete. DESIGNATED FACILITY TO GENERATOR <br /> 'letw mai%N's has th* apo agpt"AQ ptirwits toy ii will.Accept like waste the'tel it3lt►i[6 VA- <br />