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PWT-Pr01,,type.(Forth dest9ned for use on elite(12-piton)ry writer.) f prr,,Appcuved.OMR N6 2650-OUSE <br /> UNIFORM HAZARDOUS t Generator ID Number 2 Page 1 of 3 Emergency Response Phone 4 Manifest Tracking Number <br /> WASTE MANIFEST I CAt i 2I ,14,1 '14n.rJrtu 7548 <br /> G B F <br /> 5 Generators Marne and Marling Address Generators Sae Address(d different than ma•ono aCdress, <br /> t.FJ PROPFRTIE&FLYiN6 J i RIPON <br /> 3J3 W CENTER ST I?U1 JACKI0?JV RD <br /> N NTLI I.AhF 4_-1 ry.I;f W-tV.,4 MP(-IN,C.A ¢53ik) <br /> Generator's Phone <br /> 6.Transpomw 1 Compnny Name US EPA ID Numbe, <br /> 61-k_►!'IWARDS SOLIf f'16 .S l A(.lf!UI Iix1 W f4 J <br /> 7 Transporter 2 Company Name U S.EPA IC Number <br /> 8.Designated Facility Name and Ode Addruss U S EPA 10 Number <br /> liEM-RANC.T,h:1 t::lil�[u:1vA,LL( <br /> I I tZ5 WPI TE RRC K RD I}t-) <br /> RAAJCJ-ICl CORL)OVA,CA 95142 <br /> FaawysPhone 06-351-M) <br /> ga 9b U S DOT DesaVtion(including Proper Shipping Name.Hazard Class,10 Number 10 C(rlaiers 11 Total 12Unit <br /> HM arc'Padang Group pf any)) 13 Waste Codes <br /> No. Type Quantity Wt,'Vd <br /> iiAZARLXAC WASTE&WD,N O S ,9.NA3077,19 ;° N W1d 392 <br /> o (OA AJINE RL.I EIS d WAF-6)(DO 1(3) __-- <br /> 4 I <br /> w I <br /> W 2. U <br /> CD <br /> 3 U <br /> 4 t1 <br /> i 1 <br /> 14.Speaal Handlinq Instructors,aPd Additional Information <br /> FVQFILE#H la'76i (tAl?t"C H.*AP VIII Ii-Hb.Iix)bt.b 6 Nit;-,kAIIJENI�; <br /> APPROPWAIE PRO ILC11VE CLOTHWi <br /> EEE ERG#111 <br /> 15 GENERATDR'S/OFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and tabeled'placwded,and are,n all respects in proper condition for Uanspon according to applrcabre international and national governmental reg„lalons If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimvabon statement identified in 40 CFR 262.27(a)(if I am a Targe quantity generator)or(b)(if I am a small quantity generator)is hue. <br /> Gen"oeslOflerors PrmledlTyped Name Sgnalure Month Day year <br /> 16.Intematwnal Shupments <br /> 1- 11Import to U.S. ❑Expo,from U S Port of entrylexd <br /> Transporter s9nalure(for exports only) Date leaving U S. <br /> C 17.Transporter Acknowiedgment of R"iyt of Materials <br /> w <br /> T nted'Typecl ante Sina, Mmt Day Year <br /> Z Transtorhef2 Printe&Typed Na <br /> Q signature Month Day Year <br /> K <br /> r <br /> 18.Dwepancy <br /> 18a Discrepancy k.dicalbor.Span ❑ QuantityType YPe Residue ❑partial AeleGan 1 J Fun Retecnon <br /> MAndest Reference Number: <br /> I8b.Alternate Faalrty(or Generator; US EPA ID Number <br /> J <br /> U <br /> Q <br /> L, Faalrty's Phone <br /> w 18c Signature of ARemale Facility((rGenerator) IAonlh Day Year <br /> H <br /> Q <br /> 2 <br /> 19.Nazarddus Waste Report Management Method Codes(i e.,codes for hazardous waste treatment,disposal,and lu, 5 terns; <br /> N rec Yu 9 Y5 <br /> 0 1 2 3 4 <br /> 20.Udsi noted Pacific Omyer ser �-_ <br /> g y OpeiaWr.CerthGratlon of receipt gf hazardws maler.11s corered try tree manifest excepl'as«UeKii,Zlem Sal" <br /> Prinretl/TypepMarnB� 'i 'j ! ) } Signature Month D4)I Year <br /> EPA Form 8100-22(Rev.3-05) Previous edibonA are obsolete Y <br /> TRANSPORTER'S COPY <br />