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nt or e- Form designed for use on e1b(12-pitch) ewrner.) Farm Approved,OMB No, 39 <br /> UNIFORM HAZARDOUS 1.Generator 10 Numage 1 of 3 <br /> Number — 2.P .Emergoncy Response Phone A.ManifestTracidng Number <br /> WASTE MANIFEST CAD98� M -27 1 003567963 JJK <br /> 6,Generator's Name and MalllrigAddress Generator's Site Address fK different then mallM address) <br /> I,IQd'rI�9lh�>�III►tel ' <br /> 125Nl U t hUrCh Slip'" <br /> Lixi,CA 95241 <br /> Generator's Phone: 209.388.2761 <br /> 6,Transpomr 1 Company Nam U.S.EPA ID Number <br /> CaYFtst13ie EffAros>rnwitlali&Lift CAR0000M 10 <br /> 7_Transporter 2 Company Name U.S.EPA ID Number <br /> Astxxv Em*vnm9nW ABs CAV=771M <br /> 8.Designated Fadllty Name and S ieAddross r U.S,EPA ID Number <br /> iFletaG t �4� CAM10 <br /> sm S:BsYIlI69Ave" <br /> LtssAtle�alea..CA.WM <br /> Fadi G Phone: 323-42-77-1505 <br /> gA 9b.U.S.DOT Deacriplion(Induding Proper Shipper Name,Hazard assn,ID Number, 10,Conisirers tt.Total 12.Unit <br /> 13.bVaste Curies <br /> HM 2nd Pa&jrigGrnup(Mary)) No. Type Quantity WYVol. - <br /> ' Ncxt.F2GRAHardouslNeste.sali0{wt3steinkCocfi�mkrr�dtiebsis) �Q CF P 352 <br /> /00 Nom <br /> 3. <br /> a. <br /> 14.Special Handing Instru ons and Additional Informallon <br /> a,,i—wteLo tw0whit montet*bdwith ink#331222-3d ERG#1:71 <br /> 15. CENERATOR'SMFFRROR'S CERTIFICATION; I hereby dedero that the contents of thla consignment are fullyand accurately described above by the proper shipping name,and are cfassltled, gad, <br /> marked and labeled/placarded,and are In all m9pecn In proper condition for transport according tp applicable Imematlonal and national governmental regulations.If export shipment and i am the Prknary <br /> Ercponar,I certlry that the contenta of tida constgnment pn(om to the toms of the aVschad 1=PAAnknowtadgment of Consent. <br /> I cwriHy that the we ate minimization statement(dentffled in 40 CFR 262.Z7(e)(K I am a large quantity generato0 or(b)(K I am a small quantity generator)Is vu a. <br /> Genaratorslt}{fercrs Pdn ed N m signature Month Day ar <br /> 16.Interna oval pn)ents <br /> Import t0 1j 1S1 El Expertfrom U.S. Part of anhylaxit: <br /> Nnaportw stgnatura(for oxpois only): Date lowng U.S,: <br /> 17.TrenaporterAdalovdecgmentof Receipt of Materlala <br /> ns ured�� �� Day r, Year <br /> 109 <br /> Transporter 2Pdntad.ryp amnia Month Day 19ar <br /> Yl- <br /> 1k.DlaCrepancy tndloatlon Spax Quantity Type ❑ResidusPartial Ra iaction LJ FUII R.J%ton <br /> Ma^;est Reference Number: <br /> 1e1b.Altamata FaG.Ilty(or Generator) U.S.EPA ID Nuatber <br /> I Phone: s <br /> 18c.%natum otARemate or Ganeratag Month Day Year <br /> 1$.Harsrdoua Weste Report Managemem Method Codas(i.e.,coda for hazardous waste baeatmarrt,dlsposal,and recyding 9ystemr) <br /> 1, 2, 3, 4. <br /> - 1 <br /> 20,Designated F lily Qrmer or for Certification of race pt of hazardous matartals covered by the manifest except ea rwledln Kam tr3a <br /> Printed/Typed Name Month DeyWar— <br /> d <br /> 4 orrn 8700-22(Rev.3.05) Praviioue edMons are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />