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Please print or type.(Farm designed for use on elite(12-pitch)typewriter.) !"""' iia: Form Approved.OIUiB No.2050-0039 <br /> UNIFORM HAZARDOUS i-Generator ID Number 2.Page i of 3-Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST ' A. T 11 O 0 6 10949 <br /> lit ot F L F <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> !'f� ny' <br /> 1 iatd Pit# i2( <br /> I <br /> �P,CAAAA�7 �-Fp-Ui� +�i V <br /> Generator's Phone: '# 6-1 UMOdbial�imaI nwyaCA 95376 <br /> 6.Transporter i o pang ame U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> t1=HwborAriOMts <br /> LLG LiTtSS721 77 <br /> � + "1b )-) <br /> Faei f s one: <br /> 9a. 9b.U.S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(it any)} <br /> No. Type Quanfity NJt.lVol. 13.Waste Codes <br /> 0 1 UN 19W,WASTE AEROSOLS,OERt. SOL CAW,lz, <br /> 21 <br /> Lu <br /> Lu <br /> L , <br /> 2.NONE- W)N RCR.A HAZARDOUS WASTE LIOlIDS, 221 <br /> '70 7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> l.M23IM710xr&#AojXwJ,. <br /> 2.G8233674(y rnq <br /> 15. GENERATOR'SlOFFEROR'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 labelediplacarded.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 cerfify 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 1 am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator'sl0fferors Printed/Typed Name igna ure Month i-Jay Year <br /> J 16.International Shipments I - <br /> ❑Import to U.S. ❑Export from U,S. Port of entrylexit: ~ <br /> z Transporter signature{for exports onl : <br /> Date leavin U.S.: <br /> LU 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PflnfedfTyped Name <br /> y ) gnature Month Day Year <br /> QTransporter 2 PrintedlTyped Name gnature _ Month Day ` ear <br /> l8.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Parlial Rejection LJ Full Rejection <br /> Manifest Reference Number: <br /> H 18b.Alternate Facility(or Generator) U.S.EPA 1D Number <br /> J_ <br /> C) <br /> Q <br /> Facility's Phone: <br /> LU 18c,Signature of Alternate Facility(or Generator) <br /> Q Month Day Year <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3 J <br /> 20-Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba <br /> PrintedlTyped Name Signature Month Day Year <br /> EPA Fam7 8790-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> d.1Qoh Kortom has*wailflSibl iG�C: thy var{it�K Cwt t�tP .s„�iei 7 .,_.a Yutiak r t?o'ti :kr i, <br />