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SSt, SIC SHIP# 2 5028278 11111 <br /> 0064623845KS .. <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generaldr ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tradd Nlmnber <br /> WASTE MANIFEST �)' `' `� 800--468-1760 0 0 6 4 2389 SKS <br /> 5.Generator's Name and"ing.Address Generator's Site Address(if different than mailing address) <br /> fsaYcf7xer Trec k TsU/Ciagisic Sales In <br /> X77 3 'Ys3 ke Ave <br /> (� } CA 45337-9641 <br /> Genaretco's <br /> 6 7r(O1 U.S.EPA ID Number <br /> INC TXROOOO812O5 <br /> U.S.EPA ID Number <br /> y <br /> �. MADO3932225O <br /> >u <br /> ITCN LLC U.S.EPA ID Number <br /> CA 9e744 CAM44429835 <br /> �4 <br /> ' 1¢ it.Total 12.Unit 13.Waste Codes <br /> Quantity W[Nd: <br /> P <br /> t h <br /> t <br /> 4 <br /> 14.Special Handling NSWctions and Additonal Information TSD-.WI 762285234 CAI 65 MIS- <br /> 24 HR EMERGENCY #1-800-468-1760 (GH I SK I TFI) ( 0 II I� <br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby dedare Nat Ne contenfs of Nis cerrsignment are fully and acourately desaibed above by Ne proper shipping now,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper cendRlon for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> E)porter,I certify that the contents of this consignment contemn to the terms of the attached EPAAdmowledgment of Cqpsent. <br /> I pertly that the waste minimization statement identified in 40 CFR 262.27(a)(i I am a large quantity genera am a small quantity generator)is true. <br /> Generatofs/Offeror's Printed/Typed Name S' Month Day Year <br /> 3 <br /> � i6.Intemafional ipments <br /> _ ❑Import to U.S. El Evert Port ofentryleAt <br /> Transputer signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> O <br /> Transports 1 Pri ' Name r Signature Monty Day year <br /> a ^ Az vig� 3 � lG <br /> Q Transpo 2 Prim edRyped Name <br /> SignatureMonty Day Year <br /> }. 16.Discrepancy <br /> I18a.Discrepancy Indication Space ElQuantity El ❑Type Residue ❑PaNal Rejection El Full Rejection <br /> Manifest Reference Number. <br /> iBb.Attemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> aL acllhyls Phone: <br /> WC' 182.Signature of Alternate Facility for Generator) Monty Day Year <br /> Q <br /> 19.Nazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2 <br /> 3. 4. <br /> s rid Face' <br /> $ ? I'fl wrier Or Operator.Certification of receipt of hazardous materials covered by the manifest exwpt as noted in Item Ise <br /> s,a s Nam <br /> Signatureei, Mgnth Day Year <br /> qVI <br /> .? �Ytevtous edlGbns are obsolete (J <br /> DESIGNATED FACILITY TO DESTINATION STATE(IF REQUI <br /> "' " <br />