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Sep 1 . 4 2015 10,43AM HIP FaxLadds Marina 2094779585 page 2 <br />Please frintrir tvrlcifFnrrn Am"In <br />EPAFanm 7 22 <br />Rev. N5 Previo" emom are o <br />/DESIGNATED FACIIII-11 <br />14 <br />Em <br />- 1 1-1.111. <br />UNPFOltmHAZARDOUS .*.I.I.�WPU�iD <br />.--- --W41 <br />s" w- .".''.,: L' ;il. <br />12'.pagalof <br />3.EmergericyRe"ohmm" <br />11"111 _71hApproved. QIM B No, 2D5040.09 <br />4. ho 7raCid _r9r— <br />U <br />WASTE MANIFEST <br />0 04843407. SKS <br />5-GODBratork Nhma and Mmi. <br />QqViVtoes Site Addim (d Ma mailing address) <br />Laddi'� Nifir'441k. Pstric,ia, BOhnif Jt,eld <br />X511 94r� k't j Cove Way <br />ftockton CA 9W 1 1--dod-Ij <br />Generators Phone: <br />5. Tmns*,er ) 0ormany Name ..�SEP 1 ZUlb U.S. EK ID Number <br />SAFETY-KLMN sys <br />US EPA 1) Munber <br />EN ` I R NMENTA <br />CLEPN HARBORS SAN j Sr: UX, <br />1021 BERRYE&PTA ROAD <br />SAN JWIF- CA 95133 <br />Facility's Phone: <br />9a. <br />9b. U.S. DOT Description (inciuding Proper Shipping Name, Hazard Clem, 0 Number, <br />110.Containers <br />11 Total <br />12, Unit <br />HIM <br />ancl Pack" Group (it any) 1 <br />QuentIty <br />WiNol. <br />13. Waste Codes <br />No. <br />Type <br />0 <br />1 <br />"AW. 77 HAZARDOUS WASTE, SOLID, N. 0, S. <br />CF <br />PIN171 <br />DNS <br />lei <br />Z <br />'Spsclai <br />4. <br />HenciriN Instuc5oris irdAdditioral information <br />T80 --9J 6 %@836- i LP6?&534 Cgs - <br />M RENCY *1--1760 (SAFETY-KaEK) <br />TS-Irn aft468-TrL RFJI;�Thi I ICEIkI WRSEUIM CQRR <br />Jac SSR <br />r� <br />ON: I hereby dadare that contents of this co mart are fifty and c!!�cri* sb&e by 11w p-oper shipping rame, "am clueft <br />14 .1, GBERATqR'SVPR0R'S CERTIFICA71 hii, nsgn padMed, <br />marked and'labeladlplaurJad, and are in all respect in proper mridiltim for frarmport S=ttN to applutte idernadonal and national gwoommerteil regdakis. Ifexparl shipment and I are the Primary <br />Exporter, I Wr1JN that tt> . contents oftate consignment conform to the team of the attached ERA Acknowledgment of Corsets.I <br />cedify thata waste minimitzator sWemard iden!)!d in 40 CFR 262.27(a; �?f I s a large quanUty —gsnerwW) or (b) (it sural quarity gene "*< a. <br />*011W?, <br />/doPriedygName A ordh D&Y yow.? <br />118. warnato'lal ipments <br />Flimorl to U.S. Dwrtkamus Pod of erdryMidt, <br />transporter sigialure (for experts onlyI: Date leaving U.S.: <br />V. Transporter A*mA4edgmentofReceipt of MaftrW6, <br />Trans rirtedRyped eSignatr reMont D;7 Ywr <br />00--- <br />tA-N 14 11 V <br />T-ar5piffbef 2 Printed/Typed Name gnahme Month Day Yeiu <br />4Discrepahay <br />18a. Discrepancy Irdcation Space ❑ <br />Quantity, E <br />ElType ❑Rslidue El Pam .1 R*edori Ful <br />Marileat RiNnenoe Number: <br />lft Alternate Facliltj (or Generator) U.S. EPA 11) <br />A <br />N=Der <br />LA -Z <br />FadiYs Pf,,jne: <br />1.8b. Signature ofAA.Urnste Facifty (or Generator) -Month <br />Day Y0111 <br />r� <br />19. Hazardous Waste ReportMari4ef�ent Method Codes e., codes for hazardous waste tmatriwt, disposal, acrd racycingsysterrs) <br />LU <br />20. Desquilecl adlAy Owners O.pdraQor C&ffi08donofreceipt 4h=.dcta miarm covered by the marieW except as noted in <br />Print V,Typf Name <br />Month Day -rev <br />r7' <br />EPAFanm 7 22 <br />Rev. N5 Previo" emom are o <br />/DESIGNATED FACIIII-11 <br />14 <br />Em <br />