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Please print - 1T�t ENVY APR 3 o zm4 <br /> p type.(Porro designed for use on elite(12-p8ch)typewriter) - <br /> UNIFORM HAZARDOUS 1 Genemlar ID Number 2.Pa e i of 3.Emer Form A proved.OMB No.2050-003£ <br /> 9 gena Response Phone 4.Manifest Tracking Number <br /> WASTEMANIFEST (`•41.0')02?!(sf}4 01. 605672 JJK <br /> 5.GeneratcYs <br /> .:!F <br /> antl Meiling Address 1 R00-.1211-5232 <br /> Ganemtafs Site Address ill Oua mr,man mailing eddressl <br /> Tema(''Ia.-7nic�71 C„c!y�m,;f�v, :iota Omni <br /> 2302 Lark7tn Cire1�Generators1010 <br /> 6. [rst4xia!ry,, <br /> 6Transporter <br /> rFaF:sAlVa�i g3! �7s.?4g(! Skxl,-11i mnspoder 7 Co Company Name <br /> U.S.EPA ID Number <br /> Wand Fn17mnMell&Eirl P r).Bm 256,West S t0'0nLVO,C:4 9569! r <br /> 7 Transporter 2 Company Name AR000037251 <br /> U.S.EPA ID Number <br /> - 8.Designated Fal Nam and Site Address.. <br /> . . ._._. U.S.EPA IDNumber.___ <br /> Ri lugy'HayRnad .-- <br /> 6426 Hay Rol <br /> Facilkys Phone: 707451 3276 VacavtRe,CA 95687 <br /> CAD092042475 <br /> HIM 9h.U.S DDT Deal a Qntluding PmPerShipping Name,Hal Class,ID Number, 10.Containers <br /> HM and Patlnng Gmup(Barry)) 19.Total 12.Untt 13,Warm Cotler <br /> C <br /> 1. No. Type Duaney WINuI. <br /> oR Q.,NA2212,.AgBFtSTOS,9,Pl <br /> 3 <br /> 4. � <br /> 1 I <br /> 14,Special Handling lnslnidions and PAtlNonellMa•motion I <br /> EVA R*on!.Y,RAA QMR 934?616s Street <br /> San FtanefSCO,CA 94109;(415)771-6660.AStMihm Remove!Requirement <br /> 41(Ragged,mWed.labeled). <br /> 15. GENERATOR'S/OFFEROR'SCERTIFICATION: Thereby led Nal the contend M this coragam m are fillyend saumlelytlazMbed above by Ne pm perehippiry name,aid am classified,packaged, <br /> marked and lebeledlpacartled,and are in all respects In proper condition for miaccording m applicable inlemsfiniland national govemmenfal reguhho"e o4shl entandlamdle Pnmary <br /> fAr_Fixisall l Gertiy that Ins Cerlenp of fine consignment conform to the terms of the adached EPAAcgpvbedgment of Consent. <br /> I decoy that ihewaste minimirafwn statement Ideal In 40 CFR 282.27(4)(N I em a lays quantify genemtm)or(b)(BI am a smell quanlIly generator)ie We. <br /> Generalo(sris Pin nleNTyped Name ' / Signamm <br /> ��.� Month Day Yoe, <br /> F 16.Intemelpnal Shipmenm <br /> ❑impatlo U.S. ❑Expartfrom U.S. Pad ofenby/el <br /> 1 <br /> = 7 der sgnaWre(for exports only): Data leaving U.S,: <br /> w 17 TransTmnpwte ACIVIOMedgmar4 of Receipt of Mamdals <br /> der edrryped Name <br /> a StgraWm r, Month Day Year <br /> N <br /> ns a nladRypetl ams Signature <br /> Mciph Day r <br /> H <br /> 1 18 Discrepancy <br /> I 18a.Discrepancy Indicated Space Quantity <br /> 11 typo Raul ❑Pa bol Rejection. ❑Full Rejected <br /> 186,Ahemafs Facility(or Caneratm) Manifest Reference Number. <br /> .� U.S.EPAID Number <br /> LL Facility's Phone'. <br /> w 18c.Signature clishmem facility lw General <br /> zMonth Day Year <br /> W '19.Haardeus Waste Report Managemenl Mamod Codes(i e.,codes for halal wade imalment,Nsposal,and recycling systems) <br /> C F � 2. 3. 4 . <br /> 20.Designated acMfry Wmera Dperator:CedifiGah'onof receipt of hazallous matsrids orvered by Me mentlest except Be noted in item 184 <br /> Sig �M <br /> yIl PrmtedRypedN mg. <br /> reNre o Day pYear <br /> EPA Fen til(13 05) Previous wki are obsolete. 19 <br /> DESIGNATED FACILITY fO GENERAYOR <br />