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<br /> Please print or type.(Form designed for use on elite(12-p4g •.ripewriter): Form A proved.OMS No.2050-0039
<br /> UNIFORM HAZARDOUS i,:Gen®rotor ID Number2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking umber
<br /> WASTE MANIFEST_;: t :r . :.< 00145017-6 . G vR
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<br /> .5.Generator's Name and Mailing Address amara s 't tees(if different than mailing address) '
<br /> r:.. . T 1_OGISnCS.(SAf'EWAY)
<br /> Generators Phone
<br /> TiCY,'CA 115377' ..,
<br /> B.Transporter l :. :,... ._. . -
<br /> U.S.EPA ID Number
<br /> SHOP CAWM649p
<br /> 7.Transporter 2 Company Name U:S.,EPA ID Number
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<br /> A.Designated Facty,Name and Site AcUress r u s U.S.EPA ID Number
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<br /> 17VI" i� �t3
<br /> Fa sPlwne'.rd'Eff^3I51 .. ........ .., ,. •,.... r .. .. ... i1'^'
<br /> g.• 96.U.S.DOT Desc dption(ndudarg proper S ip Name,Hazard Class,ID Number, 10 Containers 11.Total 12 Urdi
<br /> HM. and Packing Croup rK arty)) ... 13.Waste Corp
<br /> . ,.No . Type (auarrtity Wt.Nal,
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<br /> W 2 RQj F—WPOCI ,txtr;s�[�4iv.,eJ!fvr'Vi3 �Is w .701,PPV - i:,.....:! J:..:< <Me �:"tr;
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<br /> 4.special Inatuctans Atlditbl irdormagoq l : a,! .... •)I:..,a
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<br /> e�eQeyy�,t�.��e..C- F J_'. ��w�qq��yy�t.s.-:.•R t ..,e.1:^ r'G. !". v:: ,_. . ,.. .. ._ ..
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<br /> 15., GENERAMs CERTIF�ATIIo(I:,I hereby declare that the contents of gaacor�nment are kily and described above by tlV proper s�ppirg game and are clasclf ed packaged
<br /> marred and lafie' gra ag respect m proper cantliHon tensport aizbMing to applicable into tpaUonal
<br /> and national gaiaAi6, regr4ahons N export shkiment and i am the
<br /> v`'E><poiter;t`&46#61:1 ®oarlerrtaoftNs
<br /> ctinsi Orient 661bmi1o.fi4 terms of the Willed EPAAA
<br /> t of CrmsanC __ r "r, ti i,
<br /> i cedifylhat grs! mW i ed 4i 40 CPR 262.2y(a)(U I'am a lige qua my=1#1(b)Cd1 am a smcligtr tity `er j t Irma.
<br /> Gf ; s r Yan
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<br /> €" 6 �ImporttotFs.
<br /> Export
<br /> r1;EI,..s,hwtaferrtry 'r,it ,ss....
<br /> ? Transporter sfgnatae(fir exports� ` , . . . Dat leaving U.S.:
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<br /> w'47.TrensobirAcimowlidgment of
<br /> RetptofMaterials
<br /> Tr 1 P'" yped g�
<br /> n.< vn, fie" Month• "Day Year
<br /> z Transporter2Ptfited/}ypedN r,
<br /> 16:'Disrsepatcy
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<br /> 18a;lhaaep p Indicafioii Space o Quantdy C�TYPe ❑Residue ❑Parliai Re)edron ❑Ful Re�eclion
<br /> t .. _
<br /> Manifest Reference Number:
<br /> 18b.Aitem�e Farxlrty(or Generate) _ ;.t -
<br /> U.S.EPA ID Number
<br /> u Face s Phorce a
<br /> 16e.Signature of Altemate Facility(or Generator)
<br /> ft
<br /> . r
<br /> Day' ..Year
<br /> 1.Hazardous Waste Reporl Management Method Codes(e codes lar hazardous waste treatment,disposal,and reeyclhV systems) —+
<br /> Notice:New federal form. State of
<br /> 2 3 California requires generator to
<br /> photocopy.
<br /> 2and mail to DTSC within 30 days:
<br /> 11.Designated Facility Owner or Operator.Certfficetion of receipt of hazardous materials covered by the anifest�except an nosed in Item 1 Ba P.O BOX 400,.Sacramento,CA 95812-0400 i
<br /> PdntedAyped Name
<br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete.
<br /> GENERATOR'S INITIAL COPY
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