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c <br /> leaseprintor type..(Eorm designed f4use on elite 12 itch ter ' ;: �w " Fonh Approved.OMB No."2050 D039 <br /> .UNIFORM HAZARDOUS 1.G ID Ntarr6er '. 2 Paget of 3.Emergency Response Phan A Tel Bamber <br /> WAS•fEMAMFEST CAD: g._8 2 5 0'.-8�2 5 4 ` . ,i =7 003214612..: JJK <br /> 5:Generatoes Name and Maung Address. G_eneratars Site Address(1f 6ftiaM than mailing address) <br /> UMed Western GrCOM U.W.O. <br /> Atte:Pet GUla mety,5204 Shelia S"et 1990 Pk=d Rd. <br /> C MMNVa CA 90040 . `Sk)daoon CA 95215 <br /> Generatofs Phdne:' <br /> S.Transporter 1 Company Name U.S.EPA ID Number <br /> Haz Mat Trans, Inc.: s C.A T 0 8 0 0 1- 2 8 0. 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number { <br /> 6 Designated Fack Name and Site Add U.S.FPA ID Number. I i <br /> DeMewaftrldocn _ I <br /> .20W-N.Akmwda Str`aet l <br /> Conn <br /> CA ' i <br /> Faa Phate:. _ :{ C A T 0 8 0 0 1 3 3' 5 2 <br /> g� •9b.U.S.DOTDescrow{ndoding Proper.Shglpug Name,hazard Class,ID Number',, 10.Contalneis 11.Total 12:Unit 13.Waste Codes' <br /> HM' and Paddrg Group(deny))° ., L. .. No. .. Type Quantity :WtNol. . <br /> c t' :NOrf-RCRA,alazerdotts•Watste Liquid . 343 <br /> �, <br /> UJIZ ° <br /> LU <br /> THIS-WASTE STREAM-HAS BEEN QUALIFIED , <br /> ' !+ s..TmE <br /> prf'!�I� '- <br /> 3 <br /> DeMENNOIKERD-00f't rACILI Y I'1 CNIPTON,, i <br /> CALIFORNIA."THIS FACII_ITY'HAS THE NECESSARY. <br /> 4•. l -` <br /> QLUWFIEDL OUR.EPA NUMBER IS CAT080013352 <br /> 14.SpecW Harrdlmg Instructions and Additional Irdolmadon <br /> t z9b `'1) di'eset/water :fto"`dean up <br /> bldrvesL Goggles <br /> 15. 'GENERATOR SdOFF17tOR'9 CFJt71FtCAjIONi I herebyCedare that the oadenlsoi this Dansignrn ant ora fully and accurately described above by ft prow shipphg name:and.am dassified,'parka*. <br /> marked and labetedlplacarded,and aro In a6 reepeds in proper oDrddcn for bar*ort acoDrtft to applicable international and national govemmentat regulatiorts.If expel shl—1:and I am the Primmy <br /> EKporrter,I certify that ttre Cant nts of dtb Consignment 66nfomf to the terms of the attached EPAAdmaededgrnent of Consea = - r <br /> I certify"#,a waste minkidr�n staterne d identified in 40 CFR 262.27(a)fif I am a large Quan*generator)or(b)(f I,am a,smati quendly generator)Is titre - F � f <br /> Ol ,,ro s yped Name ;Morm Day Maar `5 I <br /> i <br /> SErtprrrents <br /> Import OD U.9 ❑Export froirl U.S. Pat of errtrylexib r I <br /> Trarsportet s&jnakrie{far exports only}: Dam tea*v U.S.: ; <br /> 47.TranspplerAdmowtedgmerdotRecelptoflAaterlsls.•': '. . � k <br /> O <br /> Transporter 1 Pdntedrlyped Name Signature. M"M Day Year <br /> I Fi e 1 <br /> Transporter 2 Frblwypw Name SlgrtaWte M Day Year <br /> to.Dlsaepariey inificatfon Space" ❑ Quantify - ❑Type ❑.FLasidue° ❑P.Uf fte)edton ❑Frill Rejection , <br /> • r' Manffed Reference Number,- r <br /> ft Alternate Facility(or Generator) U.S.EPA.ID Number <br /> ua. FacKWs Phene y <br /> 18c re d Alternate Faci4{or Gwwa lor) - htanUr_ Day .- Year <br /> 19 1 tarardorrs Mane t McNoi1 Codes(.e..codas fa hazardous walla lrealmerd dam,and'reryc9ng systerrm) <br /> 0 4. <br /> 20.Dasigreted Fatdity O+xrer a OpeialDr Certr6ca6on of receipt of hazardous mawiata cvt-w by-ft mam76st except Qt rioted in -. <br /> Prirrtedff Nara 5 ---- —_... ()ay--,:, <br /> EPA F46 I3 Da22{Rev. )Previous edrtiana are obsolete. .. DESIGNATED FACILITY Td GS BATOR'.' <br /> I <br />