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Please print or type.(Form designed for use on elite 12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.manna Traddng Number <br /> WASTE fi MIFEST CAL000OW182 +-��3 007675664 JJ K <br /> 5. Address GeneraW3 Site Address(r different than mailing rddreaa) <br /> �a�ng <br /> P.D.mor 1958 379 Bunion AV&," <br /> III CA MMA�erlCe�.G1 05= <br /> DeneraWs Phone: MO-240-3; D <br /> 6.Transporter 1 Company NaU.S.EPA ID Number <br /> Nam <br /> Cat Iffis Ernuormun ai 8 Ultra CAR000009910 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> AsbMV EM*DfRt191ft66r*% CADOM77M <br /> B.D ted Fedi S' Ad as. U.S.EPA ID Number <br /> an i '4°oc no ro�v- CAL (UMW <br /> 5375 S.M*9 AV~ <br /> � .CA 9M <br /> Facilrtys Phone: M277-1300 <br /> 93. 9b.U.S.DOT Description(irhdudmg Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Padding Group(d any)) <br /> No. Type Quantity Milubl. <br /> 1. NWOMRAHMI1111"FiDUSWasis,Sold{Wast*Wfk ddebM1 CF oP 352 <br /> I b -. <br /> Z 2. <br /> W <br /> C7 <br /> 3 <br /> 1 e U1 <br /> 4. <br /> F- <br /> 14. <br /> 14.Special Hardmg ln&ucbDM and Additional information -;.-A 1'Yltr r 1 Celt pTq A�AIT <br /> 9.Weds debris.Plastic budob,Cor*"rmIllad wilh ink d41P17773 I ERG#171 <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acauaWY described above by the proper shippi name,and are classified,packaged, <br /> marked and labal"plararded,and are in all respects in proper condition for transport according to applicable intemrnOonal and national govemmental regulations.If axport shipment and I am the Primary <br /> Exporter,I certify that the contents of this Consignment conform to the terms of the attached EPAAcimowledgment of Consent <br /> I certify that the waste minimlzatlon statement identified in 40 CFR 26227(a)(d I am a large quantity generator)or(o)(if 1 arill a small quantity g tor)is true. <br /> Gen es/Offero's P Signa re Abnth Day (ear <br /> 16 International Shipments <br /> ❑Import to U.S Frt frOrn U.S. Port 0!en <br /> F <br /> Z Transporter signature(for exports only): Date reaviU. .: <br /> 17 TransporterAdo�t of Receipt of Materials <br /> LU <br /> Transpyl} nled Name SgnaNre Monti, Da Y <br /> O <br /> trC/L� <br /> ZQ Transporter 2 Pnntedrryped Name Signature U Morym Day Year <br /> 18 Discrepancy <br /> 18a.Discrepancy Indcabon Space ❑ 0.m , ❑Type ❑Residue ❑Partial Refection ❑Full Rejector <br /> Manifest Reference Number. <br /> 18b.Alternate Fadlty(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> laa Faclitys Phone: <br /> W Day Yea <br /> 18cSigr <br /> . hahire of ktanhete Facility(or Generator) <br /> Q <br /> z <br /> N19.h'arardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recydir g systems) <br /> � 1. 2 3. 4. <br /> __ <br /> 20.Designated Facky Owner or Operator.Certification at receipt of hezaroous materials covered by the manifest except as rhded in Item 1&a <br /> r ame SgnaWre Month Day Year <br /> { <br /> .,, 4(Rev.3.05) Previous edttons are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />