Laserfiche WebLink
Please print or +.(Found for use on elite(12-pitch)typewntu.) Form <br /> Approved.OMB No.21111639 <br /> UNIFORM HAZARDOUS I.Gandral«ID Number 2.Page tort 3.Era egen y Respo soa Phone 4. me rt Tracki Number <br /> WASTE MANIFEST CAL92fMO6362 Y a52 921—�'S61 MUMS JJK <br /> 5,Generators Name arN Maili Address Generator's Site Address If ali rend than making address) <br /> atip sF rs oxo rxM"T <br /> 13118 UMM21AIL HIl6RVAY 17121M DILL CID 8171 <br /> SANTA FE SPRINGS, CA 90670 1280 a. I li WAY <br /> Generators Phase: 562 921-3561 Attn:GRF.G rr11Gt33 S'R7Ca'[ffi/ CA 95205 <br /> 5.Transporter 7 Company Name U.S.EPA ID Number <br /> ADMIS "RV CES , IRC. CAR000189431 <br /> 7.Transpamn 2 Company Name U.S.EPA ID Number <br /> 8,Designated Ferd'dy Name and Site Address US.EPA IO Number <br /> DHtHI/(tF�tUCIf]li <br /> 2000 R ALANWA STPEXT CATOBOO13352 <br /> tom, CA 90222 <br /> Fad' sPbene: 310 '599-7 EQQ <br /> So. 9b.U.S.DOT Description(including proper Shipping Name,Hazard Class,ID Number, 18.Containers 11.Total 12.UM <br /> M and packing(Aap(dary)) 13.Waste Codes <br /> H <br /> No. Type Ouanlsy WtNd. <br /> w NOM MPA <br /> tlANDUVC Hp " P0 tWAIGR WITHAi ) i <br /> ) <br /> n' I <br /> 14.Special Handing lnsWctioa arMAdStianal Information --..`.:. ... _ -^^... <br /> Alli EYE COli i WAR CC68EC 8LMS EM 128 <br /> L[HrrkA'TDQ- 'rAI11HA & ASSOCIaITE$, ICC.. pimp WITH "YORCICARAOCS <br /> 15. GENERATOR'SIOFFERDR'SCERTIHCATIDN:I hereby declare that the contents of this consignment are futy and amralely dssabed above by the proper shipping name,ardam descried,paclui <br /> marked and Iandledlphoanded,and are in all respects in poper condition for tamped according to appbabls inu natiororland national governmental reguad ons.9 aped slnpment aM I am the Primary <br /> Eaporla,I certly nat the contents of tusconsignment corrlerm to tie terms W the attached EPAAdmwledgmerd of Consent. <br /> I cerify that the waste mirimbadon sfaternerrtidentltM in 40 CFR 26227(a)(d1 am a large quarrtty germnter)a(b)(81 ama small quantitygermalor)Is trim. <br /> Genamunsr0ltsmrs Pdrdedrryped Name Signahae I - ; Month Day Year <br /> j 16.International Shipments <br /> ❑ <br /> r Miert to U.S. El Event lrom U.S. Pad of enbylexit: <br /> Z Transporter signalum pa exports only): Dab leaving U.S.: <br /> W 17.Trasporbv Amwtedgmerd of Ramipt of Materials <br /> K Tnnshorter l PdntedRyped None - 5gebmFs' Month Day Year <br /> Z Transporter 2 Pinledrryped Name SIT"" Monts Day Year <br /> K <br /> E- <br /> 18.Diiscrepancy <br /> r 18a Discrepancy lndaton Spam ❑Quantity ❑Typal ❑Residue <br /> ❑Petal R*cd n Ll Ful Rejection <br /> ue..ao�r oore,a,o u,mno. <br /> 181b.Alternate Faculty(or Geaaalnr) S EPA(D Number <br /> GENERATOR <br /> Faolitys Phare: <br /> uu 18c.Signaure ofAflemate Facility(or Generator) MUE Day Y� <br /> i Itis your responsibility to make a copy <br /> N 19.Hazardous Waste Report Management Method Codes(.e.,codes ton of this"Generator's Initial Copy"and <br /> o +. 2. mail it within 30 ys to: ° <br /> DTSC Generato anifests <br /> 1 zo De g aaeEaaliyamar«ocenm ceddamndfm�peorhaz P.O.Box 400 <br /> PrintedRyped Name Month Day Year <br /> Sacramento,CA 95812-0400 <br /> EPA Form 870022(Rev.3-05)Previous edlfiorts are obsolete. G <br /> FE9-TV2014 <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />