Laserfiche WebLink
Please print or type.(Form designed for use on elide(12 itch)typewriter.) FormAppfoved.OMB No.2050-W39 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response one 4.Aknflat Tracking Number <br /> WASTE MANIFEST CnO0024�805 1 300 272-6349 JJK <br /> 5.Generator's Name and Maitrrg Ald ass Generators SWAddress(If different than maiing address) <br /> ISP VEST CAA$T PQODU TiS LLC <br /> P.O. BOY 80249 DD WEST COAST PRCID11CT11! LLC 6060 <br /> RASCM SANTA 1l hWARITA, CA 92688 85 E. LDUXW AVEM <br /> Generators Phone: 800 272-6349 AiHm 7 XTMM CA 95330 <br /> 6.Transporter 1 Company Name U.S.ERA ID Number <br /> ADAM SUMMS,, 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Del/FC�tUODH <br /> 2000 H_ AIJV49DA SCAT080013352 <br /> CMPTOY, FA 90222 <br /> FadWs Phone. 310 6,31-7100 <br /> 9a. 9b.U.S.DOT Description(ndud'ng Proper Shipping Name,Hazard Class,ID Number, 10,Contairwra 11.Told 1Z.Unit <br /> HM and PeddN Group(d any)) No. Type Quality WtA foL 13,yymM Codes <br /> 1.MIT 7RHOOS Nam 1.1061DD <br /> O `� <br /> FI TT <br /> z 2. <br /> W <br /> f.7 <br /> 3. <br /> 4. <br /> 14.Special Handtrg Instrucdorda and Add'ihonal Inbrmation 2, 141 OIL <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of tido consigrmwl are fully and acgratefy denoted above by fa proper shi*V name,and are classified.padwged, <br /> marked and latwledlplecarded,and are In all respects in proper cardibon for transport ac00rdlr19 to appk&*intertwtiorml and r4ortal goverm ental regwatone.t sport shipment and I am the Pr" <br /> Exporter,I cart lY that the contents of this consignment conform to tw terms of the atadded EPAAcImWedgnwnt of Consent. <br /> I certify that the waste minirrizatlon statement kientified in 40 CFR 282.27(a)(d I am a large quantly generator)or(d)(If I am a wW quantRy generabr)is true. <br /> GerwratoeslOfferors Prirdad/Typed Name SignaNrq Month Day Year <br /> L 1 12- 1 13 110 <br /> J 16.Intemational Shipments y <br /> ❑Import to U.S. ❑E*ort from U.S. Port of enfy/wat <br /> Transporter signature(for exports onty): Date leaving U.S.: <br /> 17.Transporter Adwwledgmerd of Receipt of Materials <br /> Transporter i Pdn WTyped Name Mcr* Day Yaw <br /> Q0 At ag 70, L t.v N <br /> Z I Transporter 2 Printad/Typed Name S'gnatrae mom Day Year <br /> 18.Dwepanuy <br /> 18a.Discrepancy Indication Space ❑ gdpntty ❑Tyle ❑Resbue ❑Partial Rejector ❑Fri!Refection <br /> Marrfest Reference Number <br /> 18b.Aftemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> v . <br /> ra+- Faalitys Phone: <br /> W 18c.Signature of Alternate edify(or Generator) Month Day Year <br /> Z <br /> 0 19.Hazardous Waste Report Management Mefwd Codes(i.e„codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ C3 1• 1 3. 4. <br /> 20.Designated Facity Owner or Operator.Certification of receipt of hazardous materials covered by tw maddest except as naiad In Item 18a <br /> yped Name Month Day Year <br /> AQ �Ack 5 <br /> EPA F 870022(Rev.3-05) Previous editions are objoleW TRANSPORTER'S COPY <br /> 001 <br />