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Please print or type.(Form designed for use on elite(12-pilch)typewriter) - Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pegs 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST ri .:�i_', i-')-,.+ 'I F.a'% 7U;"i 00 0 , 8 5 9<fj 1 FLE <br /> 5.Generators Name and Mailing Address Uen mtars Site Auctions(if Moslem than mating address) <br /> `*mom '1,J0'::2 <br /> Gen'erorord Dhane: 9kb:-i20"v-n??)1J <br /> .Transporter 1 Company Name U.S.EPA ID Number <br /> .l 'cot <br /> �'. f i),41 F. At cc 1 1 Lr:: i. 1(`K.. `:�>�—Ll S.: <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and See Address U.S.EPA ID Number <br /> FaorliFjs�Pd'ohe: <br /> ger, 9b.U.S.DOT D%MpUon(Including Proper Shipping Name,Hazard Class,ID Number, 10,Canblners 11.Total 12.Unit <br /> HM and Packing Group lif any)) No. Type all Wt/ypl, 13.Waste Codes <br /> 1. <br /> i�;7)':- <'u,"'r+ '✓';i,-:a•:iM?kj'fI5_5t0a, I_!...{i::l: <br /> ad <br /> Z <br /> W <br /> 3.FOR RECYCLING/TREATMENTATTHE __ I _ <br /> DeMENNO/KEROOON FACILITY IN COMPTON, <br /> NECESSARY <br /> 4 PERMITS TO RECEIVE YOUR WASTE STREAM AS <br /> QUAil 01IR FPA Pi <br /> 14.Special Handling Insbuclims and Addlgonal Informs on <br /> X ....a n <br /> 15. GENERATOR'SIOFFEROWSCERRFICATION: I hereby declare that the conteritsof this consignment are fully and accurately described above by the proper shipping real and are classified,packaged, <br /> marked and IabeleN'placamed,and are in as respects in proper condition for transport according to applicable imematlmal and national gov@mmental regulations.It export shipment and I am the Primary <br /> Exporter.I codify that the contents of this mm,gnmenl confterm <br /> orm b the s of the attached EPAAcknoededgment of Consent /I <br /> I certify that the wane minimization statement ideril in 40 CFR 21 If l am a large ardently generator) (if l ams imall quantity Wei is he. <br /> Genamuw saurfrerors F(TAINI I yped Nameturwtura <br /> ..r 16.International Shipmenra ❑Expert from U.S. Pw(bfen <br /> p- ❑Import to U.S. by/rdo <br /> Transporter signature fa%opi only): <br /> Date Qving U.S.: - <br /> K IT TampoMrAcknexledgment of Retails of Materials is <br /> 191 Transporter 1 Passel Name �- Signal Month uay er <br /> / l r <br /> Vu�✓!�� 1`f t�f <br /> re Tashi Pdmme edrfyped Naignature` 'in ay ear <br /> C <br /> H <br /> q lv <br /> 18.Discrepant/ <br /> Ise.Discrepancy lndiwtia,Space ❑I ,Canaayry.��/A/' El Type ❑Residue ❑Padial Rejection Full Rajectur. <br /> i Manifest Refererrz Number: <br /> 1ab.Nlanew Facility(or Generator) /Y 1 / U.S.EPA ID Number <br /> V !LJ F lL <br /> LL Fadi 's Phare: <br /> 1Be.Signature ol'Altemate Facgity(or Generator) Month bay Year <br /> 2 <br /> W19.Hazardous Waste Report Management Mathod Codes p.e.,codes for hazardous waste treatment,disposal,am recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Faality Carrier or0peaton Certification of receiptof hazardous materials covered by the moraesmetal as noted to item l8a ` <br /> PdmedpTyped Norma j Sigraiyie J,• Martin Day Year <br /> r"� �'`i}f./� f �!�� EJ l�:�t2�,J' �``� ...T s'✓. "`-:�i i'..'T'�a` �" '�'-''a It <br /> EP Fomr, 0D-22(Rev.3-05) Previous editionsare6baoete. - DESIGNATEDFACIL TO GENERATOR <br />