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r i Please print or e.:Form designed for use on elite(12-piton)typewriter.) Form Approved.OMB No.20513-0039 UNIFORM HAZARDOUS 1,GeneratorlD Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C k,'L.0 C'rr C)2 4'-.1am �Git�)4�2•�a-i'isowx 0140515"9 **' J J K 5.Generator's Name and Vailing Adores Generators Site Address(i(different than mailing address) r'.Q.SEk'XU107 ' r Get vetol CA. q_12CX3 Generator's Phone: 2 R -a 6.Transporter 1 Company game, U.S.EPA ID Number 7.Trarsporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and,Site Address U.S.EPA ID Number n7 5-SGUM.Rolu AVENUE 40uG.='J£"eH'SrfEnF ELY,. Faclity's Phone: S- ;r77 4 E. .. u A C r 9 7 0 0'e a ga. 9b.U.S.DOT Description(Includ ng Proper Shipping Name,Hazard Class,!D Number 'Gontairiera? 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No, Type Quantty 'vV:.Nd. o N0r�-�ds;HkZA�•.DW., ;SO,..te= (01.1-Y SOLIDS) DM Uj Vi t 4. ENCH HEM-T+ 14.SpecIakHandkng Instructions and AddWW Information ^ C, EMEE sEN9&QQhIBIlCT!Cl1EAtFI C R.MAk'IA,-pkc�-!t r a O'n:A:�1 E7;,4 0,LY PON A110204395 *APMOPPIATE PERSONAL PROTEMVE OUPMEi _� ;; ,� ` �G. ,`;�7 7/ 16, •49NERMR'$!OFFEROR'S-GERTIFICATION: I hereby declare that the contents of this conslgnment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked iand labeledfplacarded,and are I.n all respects In proper cortdition for transport aacordlng to applicable international and natio a governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignrr art conform toi the ferr18 a!'tlle attechedEPAAcknowledgment o`Consent. I certify that the waste minimization statement identified In 40 CFR 262.27(a.(if I am a large qua,tbty or)or(b)(jf I art a small quantity generator)Is rue. G G's/Offerors PrinteoRv i Name e ' ! Si tur (y Month Day Year 16.Inamatlortai 59lpmehts ❑Import to L.S. Export from«.S. Port of entrylexi- Transporter signature(for exports only): Date leaving U.S.: 17.TransportarAdv%Watlgment of RscgW;t Malaria 9 Tran 1 Print / f Signature Month Day Year tt��f Cv '� � � / ��r.L`�'�� c--- �•L: rJ,T 133 / Transporter 2 Printaot 1YPeQ Name grature- Month Day . Year 18.Discrepancy 18a.Discrepancy Indication Span ❑ lluantiiy []Type Residue _._.Partial Rejection ❑Full Rejecticn Man^est Reference Number: I Bb.Alternate Facility(or Conerator) U.S.EPA ID Numper FadWs Phone: W 18a Signeltrte AMertgte fadlRy(or Generator) 7Month Day Year - Z 1 1 19.Hazardous Waste Report Management Metttod Codes(i.e.,codes for hazardous waste treatment,disposal.and recyc5ng systems) 131. • 2 ° 4. .- 20.Daslgitalled Facility Owner or Operator:Ce lliieall of receipt of o •rate' covered by the manifest,except as noted in Item I Sa j Noma Signature / Month Day e9r:': EPA Form 8700-22(Rev.3 Previous add DESIGNATED FAF I.I YTO GENERATOR STATE(IF REQUIRED)