Laserfiche WebLink
1,ease }ipnt or Type. (Form des---- a (12 -pitch writes) <br />u <br />art oup m� qn�n-nngo <br />rrm rorm oruu-« trcev. ruaf rrevious eamons are oosoiete. DESIGNATED FACILITY TO GENERATtiR <br />HAZARDOUSNumber2. <br />�Wj <br />Page 1 of <br />3. Emergency Response Phone <br />MANIFESTJJK <br />5. Generator's Name anti v gAcaress Generator's Sife Address (if different .- <br />(1IAY <br />t iff <^t ::•< CA fi 6 a0j <br />Generator's Phone: <br />6. Transporter 1 Company Name, <br />7. Transporter 2 Company Name U.a. _ ;. <br />8: Desfgnatedfaditg Name-and"Site`Address • z. �:x .� 7 'U.S. EPA, -- <br />. A,-- <br />"` <br />�t'�:il.:-�..i'"i.'l:'„."�'".f...'5.'��'a{: i�..�` C.?7-i.}'�'�':''i� er 4�;r�_ y,-_..,;_ 1,.......:'a....�..,._.. `..w..:r�, �.,..e. U.. ... �.:.s 3.. +.. :i.•._.,_ _..._._ _.� - - .. <br />3150 <br />LOS s` NbE1.ES, CA 90023 <br />Facility's Phone: f Eli' 'i 499-714E) <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11 Tc:= <br />HM <br />and Packing Group (if any)) <br />Quarnt y <br />- 3. V VIaste Codes <br />No. <br />Type <br />r <br />®PG <br />-H, t=tt,,j, (DLoJ 1) <br />t'Itit <br />t fi <br />Z <br />2iV'��'F"t'-t"C✓"5i""�M',`ki'9 v'F4Y�•�:•�L7.�^..Iw1$''t•'•s Y�._ _ ¢.i. i'_ <br />3. <br />f <br />4. <br />—: <br />€€€ <br />14. Special Handling Instructions and Additional Information <br />9bl) A t 6329 j o,ag#gr rsy m- <br />pa yl <br />r <br />�2 tq.�*j 4w: i^ -r. i...J �.TRG i F L,.•B �.V i. L. La i-61_4 <br />,bf¢, <br />tti•t <br />TRANSPORT'E'R 1 I' i"i () t',1, F * 1-800-752-1G66 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If ??port shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terns of the attached EPAAcknowledgment of Consgnt. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if 4m a small quantitypfierator) is tru�e- <br />G eratoes/Offerots Printed/Typed yp� Namei Signature %/ d Month ` Day Year <br />� <br />J <br />16c atemational Shipments <br />❑ import to U.S. Extort from U.S. Port ofentry/exit <br />Z <br />Transporter signature (for extorts only): Date Ieaving.U:.: <br />U <br />17. Transporter Acknowledgment of Receipt of Materials <br />LE <br />Tran dntedtryped Name { Signa moo try Day Year <br />�+ <br />19 <br />03 <br />. <br />Transporter 2 Pnntedli ypmt Namegr�a re Month Day Year <br />H <br />18. Discrepancy <br />18a Discrepancy Indication Space <br />pam0tY � �.�4 . �-ypeOPafUal }�ejecpon ❑ FyliRejecbon <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />rJ <br />Facility's Phone: <br />LU <br />18c. Signature of Ntemate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />US19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />® <br />1. 4 <br />2. <br />3. <br />4. <br />20 Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printedrryped Name Signature 4 , f Month Day Year <br />�...,•. ..ay.+ <br />'4' Raw-.. <br />,t ."""✓'.� h l� ' .t # i% / „% + <br />rrm rorm oruu-« trcev. ruaf rrevious eamons are oosoiete. DESIGNATED FACILITY TO GENERATtiR <br />