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Please ip int or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMD No.2050-0039 UNIFORM HAZARDOUS 1/Geenerator ID Number 2.Page 1 of 3.Emergency Response Phone 1.M(annliest fTrrackkiing Plumber p p p WASTE MANIFEST I(.��b(d 0 � � ��(� I Cow,i '1-.2f 3 I V 0 V L; 18 1�� lvJl�ll'� _ 5.G eralo s name and Mailing Address Generators Site Address(d different than mailing address) szo Generalofs Phone: l)t®Q ° y®� G.Transporter 1 Company Name U.S.EPA ID Number EIWIM-11TVIE11"1'AL LOGISTICS. IN � (:J\R0lJ0217:513 7,Transpoder 2 Company Name U.S.EPA ID Number . 8.Desinated Facility Name and Site Address I U.S.EPA ID Number FI1 TER RL-CYCL11,IG SERVICES. II`1i_. C',AD9874444-D1 180 WEST MONTE AVEHUr RIALTO,CA 92316 US,"x Facility's Phone: 800-699-4377 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,tD Number, 10.Containers 11.Total E12.Unit 13.Waste Codes HM and Packing Group(If any)) No. Type Quantity o ON F r /570 a Z 2. rLLI 4. 14.Special Ha citing Instructions and Additional Information Oe1) 5 ®�a�i�©� VVEARAPh-RCIFIRIATEP-P-e If 9a2) yes) gRli 1 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the conlenls of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledlplacarded,and are In all respects In proper condition for transport according to applicable International and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement Identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(IfIAT a small quantity generator)Is true. S p Signalur e, , Month Day Year General 'sl0lferor's PrintedRyped Name � � -in emational Sh ments ExYt port fro S. Port of enlrylaxil: — — — ❑Import to U.S. P — Transporter signature(for exports only): Date leaving U.S.: LU 17.Transporter Acknowledgment of Receipt of Materials LU Month Day Year Tfansporta Pri tedrTyped Name - ]Signature11 ranspouer 2 PrintedrTyped Name Month Day Year n 18.Discrepancy 188.Discrepancy Indication Space Quantity I__I Type ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number: --- 18b.Alternate Facility(or Generator) U.S.EPA ID Number U Facility's Phone: I Month Day Year w 1(tc.Signature of Alternate Facility(or Generator) 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) I — Q4 20.Designated Facilllyy Ovmei or fperalor.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a _ Signature Month Day Year PonledlT ed Name / EPA Farm 6700.22(Rev.3-05) revious editions are obsolete. DFSI 6YIf-1"! ()t�11f�ILI T V TO DE=STHNLIVI E�3 U S�,WE OF G7E�L1PN![-:®)