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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.GeneratorID Number 4.Manifest Tracking Number WASTE MANIFEST (—AIJ3WJ0.31iU4 pf _7age 1 of 1 3.Emergency Response Phone 209.11�34Ll--11111c�I " I�, '� I" — - 'n GBF 10?-J ., J 5.Generators Name and Mailing Address Generator's Site Address—(-if—different than mailing address) BOY, 3,lrc. 5151 I-A1JvA1C.)IAID1qV( '10�1 -'XD-i 161 Generators Phone: K 6.Transporter I Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number Mvo)i I.,I vsj k'-f't Y 3,1 i I-i.-.fo;; B.Designated Facility Name and Site Address YLIN1,1A YLII-p IJA� U.S.EPA ID Number '2 1. L Facility's Phone, ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. 1. 0 '2 7,'j Ja 31?111 Z 2. LU 3. 4. 14,Special Handling Instr ,;.5tlons.ancl AdAtional Jn ation C;IZ�-110 7 1 �AC 1111'---fliaRCI J-1i"Y fll'04 "I':J0631 15. GENERATOWSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary:- Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(iff am a small quantity generator)is true. Generatoes/Offeroes PrinlecIrryped Name Signature Mopth% Day Year _j 16.International Shipments 1:1 Import 1.U.S. ❑Export from U.S, Port of enlry/exit: Transporter signature(for exports only): Dale leaving U.S.: w17.Transporter Acknowledgment of Receipt of Materials F- Transporter 1 Prinledrryped Name signal oMonth Day Year z: Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space 1:1 Ouantily El Type Residue ElParlial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number —J LL- Facility's Phone: M LLj 18c.Signature of Alternate Facility(or Generator) Month Day Year ti19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) LLJ 1 1 ' 20,Designated Facility Owner or Operator.,Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Notice State of California requires Printedrryped Name Signature generator to photocopy and mail tO DTSC with 30 days: