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Please print or type.(Form designed for use on elite(12-pitch)typewrite) Form Approved,OMB No.2050.@4.39; <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 N 3.Emergency Response Phone 4. an est Tacking u <br /> WASTE MANIFEST ICA <br /> � A 1 000 ? R O T R A. 1 90-424-9300 1 1 F JJ K <br /> 5.Generators Name and Maleg Address Aa:3NaIM1 WtfNa Generators SireAddress gfdlAerent Man marling a rens) <br /> --90"wey"It FiAftWXV FUM 02707 <br /> 5818 Sbmddge MAN Road:Agn:Sheen Pinups 6426 N PocM Ave <br /> Pleelsenlon CA 94688 ShwIdDn CA 96207 <br /> Generstofs Phone: - <br /> B.Transporter t Compadry Name U.S.EPA 1O:Number <br /> FrwkonmenW Logue:*• C A16 O O D 2 1 T 5 1 3 <br /> 7.Tanspater2 Company Name a - 'US.EPAIDNurnber <br /> 8.Designated Faddy Name and Sde Address U.S.EPA ID Number <br /> HBZ M1 IM, <br /> 6300 Sbdlrn Or <br /> Kana&Clly MO 64129 <br /> Fadllys Phone: 919 9246984 IM O D 8 8 1 1 2 3 3 9 1 <br /> Sa. 9b.U.S.DOT Desorption(rndudi g Proper Shipping Name,Hazard Clens,ID Number, 10.ContainersType 11.Total 12.Unit 13.Wass Codas <br /> HM arNPadrirg Gaup(gany)) No. Quantity WLNci. <br /> 1U0993.WASTE Fla1n rlumbb Ngtdds nos.(gaacllnel,3,FOIj 01 HriB :a', <br /> 2. <br /> 3. <br /> 4 -.. `r.. <br /> �."• :AwcvM^+ae!'c?^h' g^L$�4'(ilMi.x. ..« ..b.�..,-.,. - - ... - ,. - _. ,,_ - <br /> 'r 12.Special Handling Instructions andAdStlonall aeon mA,E)AbW#W*_GAAWnASWAk -AE868742ERW29 NW017 I N4 <br /> 15;,OENERATOR'S1OpfEROR'S CERTIFICATION: 1 hereby declare that Me contents of this consgnmem am"arid accurately described above by the propershipping name,and are dassifted,packaged, <br /> marked and labeledlplacarded,and are In all respeds in proper condition for WnsprortacorA'ng loapptic"kdemaporet and national governmental regulations.If export shipment and l am the Primary <br /> Exporter,I.ceddy Mat the cements of this consignment conform to the trams of the aGaited EPAA`dmowledgmem of Consent <br /> I cedrfy that the waste mimmizaaon statement Mended in 40 CFR 262.27(a)(1 11 am a1arge quarry genember)or(b)(dl am a small quantity generator)is rue. <br /> Gemrabrs'Ol!erprs Pdn _ Signature ;„'/• Month Day Year <br /> �-j /'✓r Ja'''r!•✓ �° S It <br /> •• a16.Infema8onal armnis <br /> F ❑Impatta U.S. ❑Expari frmn U.S. Pod of entry/exit <br /> -= TansDare leaving U.S: <br /> W 17.Tanspabr"unvledgmeddReeeiptofMaferias <br /> SigneWre Month DayT rear <br /> 11- TMWOrftlgr1 n pad Name <br /> _ <br /> ZI raspodar2 Pdn me SignaNre Month Day Year <br /> !- 18.Discrepancy <br /> t 18a.DIscrepancy Indication Spam ❑ Oue gry ❑Type ❑Residue ❑Paw Re co, ❑Full Rallthan <br /> Manifest Reference Number. <br /> 18b.Alternate Facey(ar Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL <br /> Faculty's Phone: - - <br /> w <br /> 180 Signaftwe of Altercate Faclity jor tor) Month Day ear <br /> a <br /> z <br /> S2 19.Hazerdos Waal Report Management Method Codes 4.a.,codas for hazardous waste basement.disposal,and recycling systems) <br /> 1.. - 2. 3.. .. <br /> 20.Designated Faculty Owner or Operabr:CeNBcaM1an of amlptof hazardous materials covered by the mendest except as noted in applies- <br /> Pnn yped ma Siqft7w-M7 Monthay Year <br /> (3PNAA) I i If b <br /> EPA Form 8700.22'(Rev.3-05)Previous editlons era obsolete. ._ DESIGNATED FACILITYTO GENERATOR <br />