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Please print or type.(Form designed for use on elite(12-pitch)typewnter.) Form Apmved.OMB N0.2050-0039 <br /> UNIFORM HAZARDOUS 1 GenerAv ID Numbef 2.Page 1 of 3.Emergency Response Phone 4.Manihot T umber <br /> WASTE MANIFEST CAOo M402 003568460 JJ K <br /> 5,C- ��Addrrss Generators Sin Address(If dNerent than mailkn address) <br /> P.O. a 109e 27x1 BuS m Aw emr <br /> MW CA M38 AIIr1C�ra,Cal >t►�se <br /> Generator's Phone: MO-240-SM <br /> U S.EPA ID Number <br /> 6 Transporter 4comima�� STM <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 6.DesC� gpO Sr a Ad Com. U.S.EPA ID Number <br /> S1Ts3 s.DO�Mi IVw►IIr CJ1D0o70.UM <br /> Los r ,CA 9M <br /> FaciiilYs Phone: 323'2"'l M <br /> 9, 9b.U.S DOT Desaiptim(ndudng Proper Shipping Name,Hazard Class,U Number, 10 Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Pad*Group(it any)) No. Type Quantity MARDI. <br /> Cr <br /> 001 N" <br /> Z 2 <br /> w <br /> 3. <br /> JR <br /> 4 <br /> i <br /> 14.Special Handling Mc�5 <br /> sbu «K and Mctibonal Information ENVIRONMENTAL <br /> ttl.Weng$i.Oak hCIt#L>i,cAf 1� k*MROOM A4PAITWnr:PQRTNAPNT <br /> 15 GENERATORWOFFERM1 CERTIFICATION: I hereby dedane That the contents of this oonsignvnbnt aro fully and accurately described above by the proper Shipp%name.and we landed,packaged. <br /> martred and labetedlpWa dad,and am in all respects in proper condition br transport according to applKwe udernadorW and national govemmentel regAaWnG.M export shipment and I an the Primary <br /> Exporter,I ce"that the contents of this consignment COO 1h to the terms of the attached EPA AGnnNbdgment of Consent. <br /> certify that the rnrr nization staament klended In 40 CFR 262.27(a)(d I am a lege quannty or(b)(if 10 a vA qua ter)is <br /> Gen slDRerors r Month D Year <br /> 1611171 <br /> VI <br /> F 16.1 Shp-* Export from U S Port d entrylaxiL <br /> z Transporter signature(fa exports only): Date U.S.: <br /> 17 Transporter Admowladprrnt Of R 01110 Of MOM" <br /> QTM'"WftP*W Name Signature Month Day Year <br /> / <br /> IL , 611 111 I <br /> = Tron Name Day Year <br /> cJT.4 2x q's, <br /> Ad 0 <br /> D/ le <br /> 18.Deaepancy <br /> 189 Ddaepancy Indication Space ❑ ❑Type ❑Residue ❑Partial Rejection ❑Full Rection <br /> Manifest Rekrence Number. <br /> 1 O Alternate Fadlly(or Generator) <br /> U.S.EPA ID Number <br /> J <br /> v <br /> illi FacanysPhone: <br /> W18c.Signahrre of AMemate Fwility(«Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Repos Management Method Codes(i.e.,codes t«hazardous waste tnaMWL dopase,and recycling systema) <br /> D 1 2. 3. 4. <br /> 20.Desgnated Facility Owner of Operator Certification of receipt d hazardous malerWs covered by Ne manftst except as noted in Item 18a <br /> PrintedfTyyed Name Signature Month Day Year <br /> EPA Form 870D-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />