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w -,U (nev. rtia) rrevtous eaoons are omiete. - `- - — - = — - DESIGNATED FACILITY TO GENERATOR <br />RECEINIc7f) <br />or type. (Form designed for use on elite (12 -pitch) <br />C'r I ''' ° Form Approved. OMB No. 2050-0039 <br />RM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />F3. Emergency Response Phone 4, <br />Manifest Tracking Number <br />TE MANIFEST ' +3 :S <br />%i <br />I <br />:i?;`y �a ;j <br />.- <br />;ef J J K <br />4J t;t <br />atois Name and Malting Address <br />GenerabfsS160aress(rfdflfererdlhenmmigl <br />:'•teieane'a••ngAdd <br />.4i r r ;'n_1r i ��ily:rgi_r <br />!l u}�'I' s�.i 1 I �L7EJT <br />;M1V e <br />JTr !ILLS 6. &-13 F -5n T OTH a f <br />,::',411E <br />CITOCkTON CA <br />Ws Phone: i_)." >,�4. 3J •i <br />,oder 1 Company Name <br />U.S. EPA D Number <br />ScRt�i(,E3 <br />Cn <br />wrier 2 Company Name <br />U.S. FPA D Nun6er <br />,sled Facility Name and Site Adds <br />U.S. EPA D Nlm6er <br />�.8 r -WE tASTEP— qom <br />a <br />Phone: O'KA6.27-7100 <br />. <br />3b. U.S. DOT Description (rndudmg Proper Shipping Name, riazard Class, ID Number, <br />10. Containers <br />11. Total <br />12- Unit <br />and Packing Group Qf any)) <br />No. <br />Type <br />Quantity <br />WWd. <br />13. Waste Codes <br />3, VqASTE PUAPMAZLE LR' <br />-N-rj3, (u,P60U <br />I <br />P <br />1HISWASTE STREAM AS BEEN QUALIFIED <br />rnr AThAm-ir AT TRE <br />,a <br />DeMENNO/KERDOON FACILITY IN COMPTON, <br />Ry <br />--- <br />—�.---- <br />TfIIS I-ACILI T Y h S TI1Ent I.ECESSAS <br />CAI NIA. <br />PERMIT STO <br />�i3L <br />iGUA11FIED OJI, kF'ta NUiy j I <br />A Handling Instructions and Additlonal Information <br />W'sa ; ; CWTig4T : C'rk--f:,ffPE- <br />: r 4.3. 0 NAER04 G-3 i . i__� :; PR, rlLE #d9i31: d � t�a�Ss111NE, a�??��� Irft-0��9.. <br />L <br />t it?, ;g , A.O�` ROF-R?LATE PER+��0RAI- <br />-ROTEINNE C-CAUPPF-N i u� t;-,\0 <br />,1 , .,Ir <br />c� �9 <br />IERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare <br />that the contents of this consignment are fully and accurately described above by the pr cper sh!pping name, and are classified, packaged, <br />led and iabeiedrplacarded, and are in all respects in proper�pndtion <br />for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Ider, I certify that the contents of this consignment conform td <br />the terms of the attached EPAAdmwledgment of Consent - <br />Illy that the waste minimization statement identified in 40 CF <br />262.27(a) (if I am a large quantity generator) or (b) (if) am a small quantity generator) is true. <br />'sr0eeror's Printed/Typed Name <br />Signature Month Day Year <br />3licnal Shipme Is <br />❑ Import to U.S. <br />❑ apart from U.S. Pod of enpjr mk <br />er signature (for exports only): <br />Date leaving U.S.: <br />bderAckuwwtedgmenl of Receipt of Materials <br />;r 1 Printed/ryped Name: <br />Signatufet AToNh t Year14"s <br />�r 2 PriMtial I yped Name <br />Signature Montt Day Year <br />panty <br />epancy Indicalon Space ❑ Quanbty <br />❑ Type ❑ Res!due ❑ Partial Rejection ❑ Full Rejeol <br />Manifest Refererce Number. <br />,ate Facility (or Generator) <br />U.S. EPA ID Number <br />'hone: <br />dare ofAltemale Facility (or Generator) <br />Morith Day Year <br />lous Waste Report Management Melhod Codes (.e., codes <br />to hazardous waste treatment, disposal, and recycling systems) <br />" <br />2. <br />3. <br />4. <br />gated Facility Owner or Operator. Certification of receipt of s materials covered by the manifest except as',o0ed In pem 18a <br />Sed Name -- — — Signature -----r....�� Mon& Day Year <br />.'.'!.•. f' z% <br />w -,U (nev. rtia) rrevtous eaoons are omiete. - `- - — - = — - DESIGNATED FACILITY TO GENERATOR <br />