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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) *';+:[ a S:FW* A-0J 4120" Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST y ;y 4 F,91 f;. FLE- <br /> F1 <br /> 5.Generator's Name and Mading Address Gen rotors i e Address(if diflerenl than mailing address) <br /> 1 -LILMd 00210 <br /> POROX1029 40*VV RDW <br /> Tram CA 9&WR rt a�,#�18�31� <br /> Generator's Phone: <br /> 6.Transporter 1 Company arae U.S.EPA l Number <br /> Clem Hors lire <br /> 7.Transporter 2 Company Name U.S.EPA 1D Number <br /> S.Designated Facility Name and Site Address U.S.EIRAJD Number <br /> 0eaftH's bffsikillINWORMLLC d$7�Q6 7$ <br /> 2500 West ttkl1111 Mod <br /> rnudkilillir.CA SON <br /> � <br /> Facility s P one: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> renft <br /> .NSI wfizs ius. > .. <br /> C1 <br /> 2 <br /> LUI <br /> c <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> f/: -o-owtleb <br /> 15 GEN ERATOR'S10FFEROR'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'labeledlplacarded,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 10 the terms of the attached EPA Acknowledgment of Consent. <br /> I codify 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 /> eneratod}js/ eror's Printed yped Name jgna ure /)on /]ay Year <br /> /J <br /> A Sw Awl <br /> J <br /> 116.International Shipments <br /> F ❑Import to U-S- ❑Export from U.S. Port of enAil <br /> Transporter signature{for exports only): _ Date Il U.S.: <br /> w 17 TransporterAcknawledgment of Receipt of Materials <br /> r <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> co Transportdr2 Prip4ciffyM Name I Signature Month Day Year <br /> R—Y 're"V <br /> 18.Discrepancy' l18a,Discrepancy Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> F 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> LL <br /> Facility's Phone: <br /> U.1 18c.Signature of Alternate Fecllity(or Generator) Month Day Year <br /> 4 <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> t 2. 3. 4. <br /> f3 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item lea <br /> Pnntedfryped Name Signature Month Day Year <br /> r141-41, <br /> r'0 lzql ,. <br /> EPA Fort 8700-22(Rev.3-05) Previous editions are obsAte. ESIGNATED FACILITY TO GENERATOR. <br /> 0*06"arid+, a las the awepoko fetimb fW ilii as tilt war dw VWAW ilia <br />