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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 12.Pagelof 3.Emergency ReVonse Phone 4.Manifest Tracking Number U010 FLE �6 WASTE MANIFEST CAT 0 0 0 6 1 0 9 4 9 5 Generator's.Name—and Mailin.1 Address Generator s.1;1,Address(if different than mailing address) 400 W Vakk-o ROW .,�. Yf ",•: t"/� Q 7� Trate`.CA W376 Generator's Phone: �` � �+ A.TTN:Debbie Tumor 6.Transporter I Company Name U.S.EPA ID Number !rr t�tai SeryraaF,Inc M A U 0 3 9 .3 a i 2 5 0 7 Transporter 2 Company Name U.S.EPA ID Number E 1.. t \1- 5 L l r-- A.at f '?'Z 8 Desn� erQJtrC��rjiiR?dI$� U.S,EPA ID Dumber idOQ Nafth Aptus Road U T 0 9 A 1 5 B 2 1 7 7 3ra-tt vik,EST�(j �'C219 Facility's Phone: I""`r ?2344'!E't ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number 10.Containers 11 Total 12.Unit HA•I and Packing Group(if any}) No. Type 11 Total 12,Uni 13.Waste Codes vol _tq'11'-:611,',AAS. TE AFERGSCL ,9AER05 fL CA s). i MiO f- 1 2. ! 77RKMOMS WASTE E,1QU1[7S,(USS C", 221 ca 4. I r 14.Special Handing Instructions and Additional Information 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. marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and national govemmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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. Generator's+OHeror's Prirntedflyped Name gnature Y on ay Year 'r_ .. 0 3 I 16.Intema6vnal Shipments z 11 Import to U.S. Export from U.S. Part of entry/exit: - Transporter signature for exports onl : Date leaving U.S.: Ex 17.Transporter Acknowledgment of Receipt of Materials t LU Transporter'i Pantedrryped Name Signature s Month ay ear O }� V zQ Transporter'PrintedlTyped Name dd i nMonth Day Year - 18.Discrepancy 18a.Discrepancy Indication Space 0 Quantity Type ❑Residue ElParlial Rejection Full Rejection 18b.AlternateManifest Reference Number Facility(or Generator) U.S.EPA ID Number J_ Q Facility's Phone: w 1 Br.Signature ofAltemate Facility(or Generator) Month Day Year Z V519.Hazardous Waste Report Management Method Codes(Le,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4, 20.Desigr6ed Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a P tntodrryped Name Signature Month Day Year EFA,Fq rn.871at1-22(Pau 3-05) Preuioywions are obsolete. accot the wa3w thY DESIGNATED FACILITY TO GENERATOR