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SCE E Please print or i W. i Form Approved,OMB No,2050-O039 UNIFORM HAZARDOUS 1 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.1itanifestTmcki Number WASTE MANIFEST i:Q$90090= 2 1925-423-42'm 019 4 4 5 5 4 7 J J K 5.Generator s Na and Magi ' Generators Site Address(H different than mailing addressl b1v saoa I`�verrrtd>re�Leb Site X00 on#3e W of U5 NPSA Pd2. U` � Liwertnat+e Nlllf{iow Lola 53te$W on beeff of t$WEA etanres I=W8/L-786 UtrertrWe(CA 94%1 HaVOW Rolxff rW CA VWX Generators Phone.925-W-LM ATTM Wppbv 6.Transporter 1 Company Name U.S.EPA ID Number Own Harbors Enviranmriltal SeMses Im MAM393222M 7 Transer 2 Company Name U.S.EPA ID Number C h i^ (fir 0 '1 F `1 2--Z 6.Des nated Facility Name and Site Address U.S.EPA ID Number Clean FI3ibm La Pw-*.LP.5W 4wbpwvLm=Prank M Sotft Lu Pc tcl TXTM1 Facilil�s Phone. ZB1464WW 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers it.Total 12.Unit 13.4Wasie Codes HM and Packing Group(i any)) No Type Quantity UVt14ro1. 1 L NMIS,Vftde,?LEnitx'y compremed,2.2[ERG MI LAi-LCY4.1 CY 14 P t] 141 OUTS 7021 2. UN20K Waste,N;MtToaM Colr WC7A d.2.2[ERG 1211 Lll4tUCY41 -1- 141 OM 7011 3 UN1045,WaSte,fako%cut WWSed,2.2 IERG 121]L].rt'L-L it 25 P 141 OMI 7021 4 UN1trlZZ,Milo, bane,2.2(ERG=1 UAL- CY'2- g CY 58i P 1 331 ours 8011 14.Special Handling instructions and Additional Inlormation Errs rGy Raspome[ rode 9Z5-4�r�onw nama UXL tE�eiv=y�.Load d LFT1401,Stdp Dw Nor S-,s frJ�SIC a rK Lielarao tef�r s rlu r LKE 6�(� on h1Ys�e.Sloe attadiled for cOl Wnet rAm9=L SILL 1 CY x 24G DF,9b.2-2 CY x 2 ea 146 DF. .3.2 CY it 14C LF. 11"" 50--W 19 pG-(7 W015 15. GENERATOR'SrOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassfied,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable Intemationaland national governmental regulations.If export shipment and t am the Primary Exporter I certify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent. I certify that the waste minimization statement identfied in 44 CFR 262.27(a)(f I am a large quantity generator)or(b)(if I am a small quantity generator)Is true. Generatorsl0fferoes Printe0yped Name Signature - Month Day Year scan A.G-aham of behalf of the NNSA f � �„{F•� 16.International Shipments El ---�-"" Import 0 U.S. ❑Expoq from U.S. Port of entrylexit: s Transporter signature(for exports only): Date leaving US.: 17.Transporter Admm edgment of Receipt of MaterialsUj ' Transporter PnnbdWTyped Name Fx Signature Month Day Year 4 Transpoter 2 Prrnnted yped `''e�+ f / Signature F Month Day Year ��,r L l ercf' ] ,� 18.Discrepancy / 18a.Discrepancy indra5on Space ❑ Quantity ❑Ty pe ❑Residua El Partial Rejection ❑Full Re}eaion Manifest Reference Number. 18b.ABemate Fa;ity jot Generator) U S EPA I D Number Facility s Phone: W 18c.Signature of Altemate Facility(or Generator) Month Day Year a z 35 19.Hazardous Waste Report Management Method Codes(i e,codes for hazardous waste treatment disposal,and recycling systems)LLI C 1 Z 3 4 2J Designated Facility Owner rator-Certification of receipt of hazardous materials covered by the manifest except as ndoin Item 1 Be n ypedName Signature /} Month Day Year EPA Form 87DO.22(Rev,12-17) Previous editions are obsolete. i DE I HATED FACILITY