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PIPacP nrint nr tvne_ fFnrm riesinnart fnr u_ce on elite 112-6itchl tvoewri'ter_I <br />Form Approved- OMB No. 205 <br />EPA Forth 870D-22 Rev -3-05) Previous eciuons are oosom e <br />Ur-ajumHi CU rAt,ILI IT 1 <br />UNIFORM HAZARDOUS ✓ <br />1 Generator ID Number <br />` -''^ <br />2 Page 1 of <br />3 Emergency Response Phone <br />AA i_i 5;..; <br />14. Manifest Trac"* <br />No <br />000 FL <br />WASTE MANIFEST <br />'' <br />��+.! :�u�...6 •w-1 i •J.G <br />.w7J%.i =f Z''i- .y <br />'� - <br />f� ? 5 <br />5 Generator's Name and Mailing Address Generator's Site Address (if ddlerent than maitirg address) <br />`.,'cast Frvojds LLC: ly:541 <br />n <br />P.O. Sax. 804 l:: 5 <br />Raldho Sapd�a t7arn-, ; CA V2,68-3 1� -�•1 .-'; r"r'1 !•i�l�'3: �!". •'i•.f a�'.Vi� <br />9i Q-4 <br />6 Transporter 1 Company Name US FPA ID Number <br />7. Transporter 2 Company Name US EPA ID Number <br />ti 7.1 1 ref .<.� {`�" <br />8 Designated FFaaTdy Name and SM Address US EPA ID NumBer" <br />La �t•Y)�[•�J i•f ��'=�lv �1JC. .^�-li T.i :3 . <br />ga <br />9b US DOT Desorption (Mudmg Proper Shipping Name Hazard Class ID Number <br />10. Containers <br />11 Total <br />12 Unit <br />13 Waste Codes <br />No. <br />Type <br />HM <br />antd9 Group (ff any)) <br />W Vol. <br />O <br />1. <br />1 Non-HLRA '.:i�31 :•=�1:s� . 7t, I•J .J:�':iL <br />y /�' <br />Joh <br />`a/` <br />v' 1 <br />Z <br />2 <br />t <br />i <br />LIU! <br />V <br />1 <br />3 <br />4 <br />14 Special Handling Instructions and Addlional Information -:Zi , <br />�i?� w {•;.�l: L� •= �� � � .' f : ate. <br />15 GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare fiat the contents of this consignment are fully and accurately described above by the proper shipping name and are classified, packaged <br />marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable internafiaral and aborraf-gavemmental regulations ti export shipment and I am the Primary <br />Exporter• I oerirfy ftl the contents of this cauigrvnent conform m the terms of the attakdmd EPAAdmowledgment of Co1� <br />I ce" fiat She waste minimization statement bentilied in 40 CFR 26227(a) (ff I an a targe Quantity generator) or (b) [d I an a small generator) is true. <br />6en7313rs106eroesPrinted/Typed Name �° , /� %f n <br />E= S, '3o <br />-j' <br />16 international Shipments ❑ Irr>port to U S ❑ Export from U S r Port of entry/exit <br />Transporter signature for exports on ): D2te US- <br />W <br />17. TrarsporterAdmowledgn1ent of Receipt of Materiais <br />Transporter 1 PrWedlTyped Name Signature Month Day <br />.•., <br />9L <br />44 <br />Transporter 2 Printed Typed Name Signature 1 mom C" <br />Le <br />18. D•rscrepancy <br />18a Discrepancy indication Space ❑ Quantity ❑ Type ❑Residue ❑ Partial Rejection ❑ Fvil R ' <br />Manifest Reference Number. <br />18b Altemate Fadlity (or Generator) U S EPA ID Number <br />V, <br />M <br />P74 &9 <br />Fadlitys Phone: <br />I Signature of Altemate Facility (or Generator) Mono <br />a <br />Z <br />{24b <br />t» <br />19- Hazardous Waste Report Management Method Codes [Le.. codes for hazardous waste treatment, dspcsal, and recycling systems) <br />G UJI1 <br />2 3 4 r <br />f f r <br />20. Designated Fadfity Owner. ce/gperator Certifxafion of receipt of hazardous materials covered by the manifest p=pt P noted in lW 18er -- <br />fk r Month <br />r , <br />-y" <br />7 <br />k AK <br />A <br />EPA Forth 870D-22 Rev -3-05) Previous eciuons are oosom e <br />Ur-ajumHi CU rAt,ILI IT 1 <br />