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3'Psoas print or type.{Form designed for use do elite('t2-pitch)'typewriter.}. Forrq Approved:OMB,No,205.4-00 <br /> 1.Genaralgf ID Number Page 1 of 3.Emergency Response-Phone • 4..Manifest Tracking NuntBaXVNIFORM HAZAf DO :WAsrE INAIVIF:ST C . � 73993 [2. -1" - I. . � oo: . _ ®� <br /> 6.Generator's Name and MallingAddress, AM: ,1i0"?KOC Generator's Site Addtoss#fdifferenl than mailing address)- <br /> �84th <br /> Tiny,'CA T CAQ6376 <br /> Generatorsphone: 08 AW <br /> 181 W <br /> `6311t-�200 <br /> -402 <br /> 6,Transporter 1 Company Name :U.S.EPA ID Number <br /> gds td1dO �?! E f_j ' 87 1) 0 7 7 7 <br /> 7.Transporter 2 Company Name U.S.y�EPA t0 Number <br /> :8.Resighpted t ac lily U.&.EPA•(D Numbar .+. -. <br /> AND <br /> Ur <br /> FacilitysPhone: � �7J AT-kf0 0 f <br /> ga. gli,U.S.60T Descdpiion{Including Proper Shipping Name,Hazard Class,ID Number, 10,'Containers 41.Total 12.Unit 13 Waste Codes' <br /> HM and Packing Group(ifan .. Nn. Type Quantity W1:Nol. <br /> Doll <br /> R1 quids. add <br /> •i603 792 <br /> LU <br /> 3. = . <br /> 4. ; <br /> 14.Special Handring.Inslructions andAddilional Information <br /> • ,tt: 91` 49 es Omer 4a <br /> 2)RO I HO.10504'OOT.ERGO ._ <br /> '1�. GENEtL f6O SfdFFERbR'S CERTIFICATION: I hereby declare thdt.the contents of this consignment:are fully.and accurately deserihed above by the prop'ersg ipping.name,and are classified,packaged, <br /> marked and Iabeier}fplacarded;and are in all respects in proper cond'ItiQri for transport according to appllcabie International and nalionat govemmentat regulations.if export shipmant antl I am the Primary ' <br /> Exporter,I.certify that,the conlents pf this consighmentcor forni to the terms of flue attached EPAAcknowiedgment of Consent. . <br /> I certify thatlhe waste minimization statement idantified in 44 CFR 262.27{a}(if I.am a large quanfily garierator)4r(b)(tit pm a small quantity generator)is true: <br /> GenerEp sl fferods PriNddfryped Name-- Signature' Manlh' pay' ,Year <br /> d 16:Intemationa#Shipmegls <br /> F ❑Import to U.S. ❑FXpoif from U.S.- Porf of entry:Mxlb ' <br /> z ,Trarasµortersignalure{for expnrls We.Ieaving U:S:: <br /> !13e97,.TtarisporlerPciinoy�ledrmentafR2cdiptofMatejiais' - <br /> 7ransporteF.9.Printa ilrypedlya_me Signature'; :r Month::';'Day <br /> Q'. • <br /> � Trans"rter'2-Printedff :i d Who C =1"ria `<Day: <br /> Po YP :. g ' <br /> 1-0 <br /> iq <br /> r YJk'�'.c+. 21 <br /> '.'i:j.'DISCre "r1C .�,. .. r_•, <br /> a f)i cre atic'Yridioali <br /> o $ <br /> P` '` ;'❑ <br /> 4Quriiltq: ��'T .::❑� . ❑PartiafP eaction'aceResd"eyPa .:_ . J. ori.c�i <br /> Manifesi.Re'ference Number: ' <br /> h}b Atteigate Facility(or Generator). U.S EPAID Numb6r <br /> FacliitV.s Phone:.:' <br /> .18c,SignatureofAllarnata.Facllity(orGeneratorJ Month. • Day Year <br /> _'�, - ���Y. .`.;xSi=s;,(s;: :.r:;i• ���`•�:;�'p-rr�.`i:.; ,r.s i.t.�:r^?�. .g.;,-:"inq;}� ,�r s'_,-; .•i..,r,�r=i-;_�;',,:�a-� r.;. -,ctS_.�-,.F., <br /> 18;{iazardou Waste Repn7i iNanagement Method Codes(i.$.,codes forfiazardorls waste treatment,disposal;and_recycding sysieths) <br /> 14. <br /> �r <br /> Q.:pesignated Facility Olijner oT Operator:CediTiealibn ofieceipt of hkkdous rnalerials.covered by the manifest exceptas ndad In Item i8a <br /> Pt'sniedlippadNam1B' 1"t 4' f r Signetare' f'.} P' ;} ' Month .`y Day. Year' <br /> . ����.`i� ykl •" �� �}4. 4.�,f' �i �. %�1�'�1:� ! C„ '` ,�"��s`��r' _� �'.," €'3 i� " <br /> 1 PR'Form$700=22(RO 3=05} I�revict s editions ora ah'sblef .. " 0SIi HAY i4�9:�3 YY. O Ca ir1 <br /> .`, . <br />