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.i <br />M.,venme nr hone lFnrm riesimred forum on elite f12 -.itch) Ncewrr ed <br />Form Approved. OMB No. 2056W39 <br />EPA FcArn 87W22 (Rev. 3-05) Previous editions are oosaem. /' I- DESiGNAT cu FAcdur r o d, <br />UNIFORM HAZARDOUS V 1. Generator ID Numbeir <br />2. Page 1 d <br />3. Emergency Response Phone <br />4. IAWefaN Trading NumWr <br />004542536 JJK <br />WASTE MANIFEST '- ACO 4 2 6 3 4 1 3 E <br />y <br />4-+} <br />5. Generators Name and Maeig Address .. Gehe2tors ^".see Address 1A different Than reaping address) <br />( I� WATGAGE Ulf; <br />fine, �IPGsrtADP M §7 1NEND RA WAY <br />FORT YYAUjNf# TOtB NA tw'— 4 _iXty? ��; ' CA 913304 <br />Gen mex's Pha e- - <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Name US. EPA ID Numbs <br />8. Designaed Facility Name anti Site Address U.S. EPA ID Number <br />DEWW40 / KER�� Q <br />MI {`)l RIH AL S� STREET <br />COWTON CA c A T 6 a r* 1 3 s 5 1 <br />Facily OsPhone: <br />9, <br />9b. U.S. DOT Description (inckdri; Proper Shipping Name, Hazed Class. ID Number. <br />10. Containers <br />11. Tota <br />12. Unit <br />13, Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (darty)) <br />Quantity <br />Wt.A/ol- <br />1. <br />O <br />a <br />t <br />n <br />WAS TE GAKA i1W. 3, LWI 2W. P G i': <br />"11 <br />DM <br />Z <br />2 <br />I <br />3. <br />L <br />i <br />i <br />i <br />14. Special Handling lnsfNChma and Addgpna Informlim <br />e&dERi�t 1441 12H'rR ftp # c i if t i�3T �3RSf lam, taTt.R R)td3E' ApITiO#�AiPACS : 80s IvtyhE" <br />APF 10+19 A E Krq, +AL PROTO +lE Etl!) PI'vUrl"'T <br />15, GENERATOR'SMFFEROR'S CERTIFICATION: I hereby declare full the wmants of this ansignmeit aefully and accurately described above by the proper shipping we, and are classified, padaged. <br />marked and Iabeliftlaarded, and are in all respects in proper condition for transport according to spill mWmatioal and national governmental regulations. If export shi imull and I am Me Primary <br />E.xeacer, I candy mat the contents of this consignment conform tithe terms of the adached EPAA.dumAledgment of Consent. <br />I testily Nat t1re waste mmirm aeon statement Identified to 40 CFR 262.27(a) (f I am a large quamay generator) or (b) (dl am a small quantity generator) is true. <br />Gene2Wrsr0Rerors PdnWyped Name Signature Mordh Day Year <br />—1 <br />16. tntamatioral Shismilints ❑ tmpod to U.S. ❑Exgnd fiom U.S -Yort of enaYlexOt <br />= <br />Transporter signature (fpr exports only). Date leaving US - <br />1% <br />17-Trdmpo*A.ckn edgnentof RecmptofMaWrials — -. <br />W <br />Transporter i PrimhipTjged Name - Ssynaara _ / _- Monro Day year <br />? . - /" <br />. <br />c n <br />z <br />Tran - P edRyped Name __-ygrbWro Mpnm Day Year <br />K <br />r <br />18. Discrepancy <br />I <br />led. Discrepancy Indication Space ❑meaty [:]Type❑ Residue ❑ Partal Rejection ❑ F.0 Rejad. <br />Manifest RoVerce Number. <br />me Alternate Facility, jor Generator) US EPA ID Number <br />J <br />U <br />uQ. <br />Facildy's Phone: <br />M.mh Day Year <br />W <br />18c. Signature of Altemm Fadity (or Germans) <br />z <br />19. Hezardaus Waste Report Managenrenl hill Codes (i.e., cedes for hazardous waste treabnen4 disposal, and recycling systems) <br />H <br />G <br />1 <br />2. 3. <br />20, DeillgrAedTaAdy Owner or Operator Cahill of mdepe of hazardous materials covered; by the manifest except as nded in Item 16a <br />Pemcf(TVPed - SgnaWrs Mmm Dry .- Year <br />EPA FcArn 87W22 (Rev. 3-05) Previous editions are oosaem. /' I- DESiGNAT cu FAcdur r o d, <br />