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t., <br />Plasm -W nr tuna Xnrm riocinnorf fnr uca nn alifa M 9.nitrhl Ivnawrilar 1 <br />Form Annroved. OMB No. 2050-0039 <br />tNA 1• rm H7UU-2Z (Kev. 3-1.1b) Nrevlous editions are obsolete. "I TRANSPORTER'S COPY " <br />J�O <br />1 <br />{ <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />6 r1 <br />2. Page 1 of <br />3. Emergency Response Phone <br />rnifest(T�racc'kiin'g')Number p <br />0097" 6 FLE <br />WASTE MANIFEST <br />-hi, 4), .'';2i 1 4 6 5 � +a <br />.L <br />000) 424-M390 <br />J i" l f ," <br />5. Generators Name and Mailing Address !tt" Generator's Site Address, (if different than mailing address) <br />.I.00 hw�'"t�llSlr�kt? l�d�'�13 <br />p.0., .BOx' 8 079.1. 1299 19. MAXI , 8m. <br />K�at��l1, +M.a 95;)36Generator's <br />Rancho Balint. Margarita, CA 9' .j'j�0 <br />Phone: (HU) '160-32a <br />Transporter 1 Company Name U.S. EPA ID Number <br />it 13'1 � CAEW0018391-3 <br />7. Transporter 2 Company Name U.& EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />+�.I� x o tl i� '� '� rJ �:.t. �� <br />��'!"d'i:.pit•��e�.'�����j;Ci�':�'��.`7 <br />Facility's Phone: <br />ga• <br />9b. U.S. DOT Description (including 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 />and Packing Group ('d any)) <br />Quantity <br />WtNol. <br />� <br />1' Nv^�xt-'1i11L"'R.& l�eyffogi�us� Ws�rsts4er•�•1,tii,f.d ' <br />Q1 <br />C'bi <br />;�(' <br />�` <br />� , <br />� <br />r <br />LU <br />2. <br />w <br />c� <br />3. <br />4 <br />14,,Special Handling Instructions and Additional Information' , r <br />t4d"R ALh l�PrrkoLwi1�1Pl�BESI <br />U1dOSMiRdVJHD 9Tl'>RAC?.cr 'PAW !'f�i)i'�:mZVE �1,�YPitxN(: 4 „. <br />.15. GENERATOR'SIOFFEROfj'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 labeledlplacarded,andare In all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and.l am the Primary <br />Exporter, l certify that the contents df this consignment conform to the terms of the attached EPAAcknowiedgment of Consent:' <br />I certify that the waste at statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />enerato a eros Printed[Typeo Name signature Month Day. Year <br />7,;tre ;400thitrt of AESI on behalf of jjenaxataa' <br />16. International Shipments r1, <br />❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: <br />Trans orter signature for exports only): Date leaving U.S.: / <br />17:•Transpoher Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature Month Day ..Year <br />Transporter 2 FMte yped Name Signature Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy indication Space ❑ Quantity ❑Type ❑Residue ❑ Pertiel Rejection. El Full Rejection <br />Manifest Referedce Number: . <br />18b. Alternate Facility (or Generator) a <br />a'� <br />t1D <br />x <br />RE <br />� <br />Feel 's Phone-.- <br />Q18c. <br />Sidrtature of Alternate Facility (or Generator) n.r^ f q. 2 Month Day Year <br />Z <br />US <br />19, Hazardous Waste Repbrt Msnagement'Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ` <br />01. <br />2. <br />3. ENVI.RO. , <br />' <br />ENT <br />20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 181 <br />PrintedlTyped Name Signature, Month Day Year <br />tNA 1• rm H7UU-2Z (Kev. 3-1.1b) Nrevlous editions are obsolete. "I TRANSPORTER'S COPY " <br />J�O <br />1 <br />{ <br />