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Pleaseprint'or Form Form Approved.OMB No.2050-0039 <br /> type.( designed for use on elite(12-pitch)typewriter•) <br /> UNIFORM HAZARDOUS 1.Generator ID Number Z Page 1 of 3.Emergency Response Phare l Yaulett Tracft Number <br /> WASTE MANIFEST CALOG -_4462 t 2 -209-M 010622972 JJ K <br /> Name tlng Address Generator's Sid Address(if ditrW Oran matt address) <br /> n <br /> ts� 278 BLAtnn Avenue <br /> �.o.ernc <br /> Mat Itaca,CA "S , Mnntacs,CA 95338 <br /> Generators Phone: 20&248-31MO <br /> 6.Transporter 1 Company Name U.S..EPA ID Number <br /> CWomia EIrrAM rental S U t1D CAR000009910 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Asbury EtTV4fDfltT1wft(=rxvrgc CAD0282770% <br /> S.Desgiated FeclMy Name and Site Address U.S.EPA ID Number <br /> Evoqw*sw Tgdrl loges LLC C F7Q3(?99 3 <br /> TS S.Bc�e Awes m <br /> LAs Angeles,CA 90059 <br /> Facilh es Plane. 323-277-1500 <br /> ga. 9b.U.S.DoT Description(ndtrdirg Proper Shipping Narne,Hazard Class,ID Number, 10. ontaulers 11.Trial 12 Unit <br /> HM � <br /> am Padug W(t a^1')) No. Type Quantity WUVd. 13.Waste Codes <br /> c 1 Non RCRA Haeraous Wasta,LJ",(Wasbalnk) DM P 331 <br /> oo / 5'6'6i <br /> Z 2. <br /> W <br /> 3. Ldt ti <br /> -- y <br /> 4. <br /> J� V� -a E411i <br /> CRE r_ n�DAIt1rRA�AI <br /> 14.Special Handing'rtutructior>s and Add tional Irdomtation D 1J5,eh— B/LL 2 lG/ .fr/r/�jlTZV>J <br /> 1.V11astB ink (, EW-4171 <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION; i hereby dedare that the oontstz offm m consgrment are fury and accurately described above by the propei shipping name,and are dassifled,packaged, <br /> marked and labeile#kacarded,and are in al respects in proper oondbw for transport accordi g to applicable nternatonai and national govern ental reguhlons.M wort slupment and I am the Primary <br /> Exporter,l mrtity that ftre cantsnb of this consignment corib n to the terms of the attadred EPAAd=*iadgrnaM of Convent. <br /> I certlly that the waste minimization statement identified in 40 CFR Z82.27(a)(If I am a large quantity gener irtp j or(b)(If I am a small quantity generator)Is true. <br /> GeneratorslDlferors Printa yped NameS gnahu//e Month Day Year <br /> rrr r �16 /S r r <br /> _1 16.International Ship7arft <br /> 1- ❑Import to U.S. ❑Evo't from U.S. Port of mtryhrdt <br /> Transporter signatue(fpr aborts only): Date leaving U.S.: <br /> W <br /> 7.Transporter Adokowledgmrent of Raceipl d Materklis <br /> Transppw Name Sgnahlre Mmlh Day Year <br /> O /�)a <br /> zQ Transporter 2 Pn nWffypedNameSgMonth Day Y <br /> nauneear <br /> Y 0 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantty ❑Typ- ❑Residue ❑Pattie)Rejection 0 Ful Rgecb n <br /> Manifest Referenm Number. <br /> 18b.Alternate Facility(or Generaor) s,-" U.S.EPA''JD'Nur dw <br /> LL Facilil phone: ��F•;- <br /> W 18c.S#iatiue of Altemaie FadUty(or Generator) Monnet Day Year <br /> 19.Hazardous Waste Reo(t Management r leerod Codes(ix.,wdas for hazardous waste treat erg disposal,and recyckW systems) <br /> 2D.Designated Fic&y tir. a0mizardous aWarials covered by the manifest reed in Ilam 18a <br /> Nertre S' Year <br /> EP <br /> �oanV22(Rev.3-05) Previous editions are oloscii. DESIGNATED FACILITY TO DESTINA ON STATE (IF REWIR. ) <br />