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Please piint'or-Ty .(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS f.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST + t s �. ( 04114`�o-�sv€ko G ,� f Q. � � i� €_t JJ K <br /> CA.L.(IQ��is ;'_? <br /> 5.Generator's Name and Mailing Address, Generator's Site Address(if differentlhan mailing address) <br /> VA>g`a 1��j�``��Eaatt���'i'�'c,.��e,��C�ct)%.-�,::�••-v�4'�r.�E�r`'f�,+; <br /> P:01 MIX 1111107 y F IY{F�,7'�l{ri`{tc�[ .�1�(3%ir <br /> ST OCKTON is = ;�?)E'1E <br /> 95201 <br /> Generators Phone: '' <br /> 8. <br /> .. Transporter 1Company Name U.S.EPA ID Numbe <br /> PAIDNumber <br /> YShRvCA'D M 2 U2 y f 0 SJ <br /> 7.Transporte2CompanyNarhe <br /> �. U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> e'+ tF.e t BBq- y. f•`S,L.ter=FP{f-•:t <br /> 6L'°.d�t��P'i 4����Fk iG:6��IF�`f~;, aF4 b::.E. <br /> LOS ANqELES C; <br /> Faci4 s Phone:: rn n �} r`-"F`, a 2 C C 13 <br /> ga 9b.U.S.DOT Description Qncluding Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quentiry WtNol. <br /> 1. <br /> 0 t'f.(S e. ,, 3. R F ( 5`Y1 P lr:.F -10 1t C <br /> 0 iV'�e 2'f"vi3LfN'>%h 4 u. F'LLl CS II M ��7I E. {rf L.Yv.��fSLL}• 'l�FY .1.—_.•.•'.. —__ <br /> Z 2, i I <br /> W <br /> 3... <br /> i <br /> 4. <br /> 14.Special-Handling Instructions and Add'tional Information <br /> F[` F¢F;ENclf"'::t_Y,tgt••T.IG'T a' _F�-`77.RE9 'i-li1:3-•rrJ4-S <br /> v wF x`019 fit.1,01 7,';f)S-,UF; 'A,r- �j R.0'Mt ;A€'E re,RS0,1AL PR"C`ECTivE EQLiIttAEii <br /> 15. GENERATOR',SIQFFER.O,R'S CERTIFICATION:I hereby declare that to contents of this consignment are fully and accurately described abov&by the propel shipping name,and are classified,packaged, ' <br /> marked aril labeleWplacarded,and are in an respects In proper condition for transport,according to applicable internattoral and national govemmental regulapons.If export shipment and I am the Primary <br /> Exporter,I cernythat the contents of this consignment conform to the terns of the attached E'PAAcknowiedgment of Consent <br /> 1 certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity gerera:or)or(b)(if,am a small euantity generator)is true. <br /> Generatoes/Offer_oes ntedlTyped Name Signatur@_., \ .Month Day Year <br /> .1 .y t ) t�ry. <br /> _j 1 16.intemational."hipments <br /> F- :: ❑Import to U.S. ❑'Exportfrom U.S. Powof entryiexit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> L 17.TrarsporterAcknowiedgment of Receipt of Materials <br /> Transpor}..y,ll Pdntedlryped N tUg __ Signature �r. �7 Month Day Year <br /> 6. .l_c`JF.,w",f ,_-i.����1='_•v4.�s�. e�.t..F'' •��� _. ..=�'......... �r� C..�:4'. <br /> a 'Transporter 2 Pri5idrrypad^Name Month' Day' Year <br /> 16,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity []Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> LL Facilltys Phone: <br /> 18c.Signature of Altemate Faciiry(or Generator) Month Day Year <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste tiastmeM,disposal,and•acycling systems) : <br /> LU 1. 2. 3. 4. <br /> 20.Designated Facility Omer or Operator.Certification of receipt of hazardous materials povered by the manifest except as noted in Item 18a ,� r.j` <br /> Pdntedfryped Name rj /+ Signature d J / Month Day Year <br /> --��f�,'7 •�'y„�-t"T S'i_i=` r, <br /> EPA Form'870D-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR-STATE(!F RE WRrED) <br /> I <br />