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Please pool or type.(Form deli nod for use on elite(12-pit -� <br /> UNIFORM HA2AROOUS 1.General«ID Number Foim proved,OMB Na.2050-003l;WASTE MANIFEST 2.Page 1 of 3.EmergencyResporae Phone 4.Maniasl7raclong Nmnber <br /> S.Gneators Name and Mailing Adtlrase ^^.�-S2.?-��t^ <br /> Geneamr5 SHeAtltlress(ffdiRerpnt than mailing atldress) <br /> stem Clgmildl relprti'al <br /> 23021MkiuCitrfe Siesd C h rriew <br /> Gone amrs Phone: :n,r+,.:^ru*t; �i i ^tq.,SO en. 1010 fialusah3l D, <br /> 6.Tanspoder l CanPanY Name (<"� <br /> 13? dfwifor; IAi .L US.EPAIDNumber <br /> 7 TmnsPorar2Compeny Name 1 {,itf'rtr .�.rT.syrr'I P.rr. 5.s ., r., '.0, <br /> .y <br /> U.Sum <br /> 5.EPA ID ber <br /> B.Designated Facilely Name and Sire Address <br /> R2Cd0$ti 1'18;'RG1tU <br /> _�t " U.S.EPA ID Number <br /> Fadli sphone: 'W-451 27 6416 Hay Rcad <br /> :1_ a VaearYlle,CA 95667 <br /> 9a an.U.S DOT Descnp6on(Indudng proper Shipping Name Hazard Class,ID Number, a"0 475 <br /> HM and Parking Group(if any)) 10.Contamers p,Total 12.Urn! <br /> 1 No. Type Ouanety WWaI. 13,Waste Codes <br /> R.Q.,NA2212,A59ESf05,4, FGlii <br /> W C� <br /> 2 <br /> I <br /> 4_ <br /> 14,Spedal Handling mitruPitm,antlAddiibnal lnformaHon _— -! __ <br /> I PA-ReVOIrlX,BAAQ11fU 939 <br /> 415 -71 <br /> San Francisco,CA 94109, . Strep <br /> e(.'FR61 (Ba€Kaci,scale.A(Iatele�fk. G660.Asbes206�`2eril lRe�grareial <br /> 15. GENERATOR'S/OFFEROR'S Crdaromall Iherzhy dedare that FhecontenR OlWs consignment are NllyaM eavra4ly described above bylhe proper sNpplrg name,and are desslfied,paskaged, <br /> marked nonfatal edlptesarded,andaremall respellsM pmpercondlbwmrIranspodaaordingtoapplicable Int'I I ''1 al and national governmental regulations Hexpodsh and antl am the Pranary <br /> Exp«(¢r.l cBdHy that the commas ofthis sansignmed Moralto the terns a/the attached EPA&M.Medgmnten/Con tan <br /> I caddy chat the waste mmimaation statement Identified in 40 CFR 26227(a)(4I am a large quanb'ty generator« <br /> GenealofyUHerdfs Pdrsal typed Name ) (b)(if I am es mall quantity generator)is We <br /> .7 Signature <br /> e^^ .57r•2 A - {J� t'' i Month Day Year <br /> 16.Iniemadonal Sh,—u. <br /> 0ImPertm U.S. LJ Export from U.S. Pannienhy7exH: <br /> = Tansponersigril(for exports only: <br /> w 17.TansporterPdmoWetlgmentofRecelga/Mate�ls Dare kaNng U.S,: <br /> a TanspoderlSignature <br /> pdrlpNry�Ilam¢ z <br /> tiaMm Day Year <br /> Transponer2 Pon@d/typed Name S"- s -w'✓ Zg f �_. <br /> SignaNre xxrJJJ aha <br /> Month Day Year <br /> 1B.Usualrr <br /> 18e.Dia«parN.y alndkation Space ❑ OuQuantity LI <br /> Type <br /> -_- DReajdue ❑PartalF.f.cnan ❑Full Rejection <br /> t - <br /> 111a Ahemale Fadlity(or Generator) Mani/est Reference Number: <br /> J <br /> V - U.S.EPA ID Number <br /> LL FaciDgs Phone: <br /> W 18c.Signature ofAlamata FadlHy(or Gerreamr) <br /> ti <br /> - Marl Day Year <br /> ty 19.HaZemnsus Waste Report Management McNod Codes lis.,codes for hazardous waste headman III I I antl recytlUg systems) <br /> C i <br /> I 2. 3. <br /> A <br /> 20.Designated Fadlity O,wier or Operator.CeNflda'on Wreoaipt olhaardous mateda's savored M'the mangestexcept es ngetl in Imm 1Be <br /> PrkrtetlRyped ame -e�__ (r Signan <br /> .' <br /> ogmri ay Year <br /> EPA Form 9700.22(Rev 345) Previous editions a obsolete. � - l <br /> u. DESIGNATED FACILITY TO GENERATOR <br />