|
Z
<br /> I
<br /> :p nt ar type.(Fo'orrl designed for Use on elite(12-Pitch)typewriter.} Form Approved.OMB Na.205D QQ39
<br /> ANI RM BAZAR©OU5 1•Generator ID Number 2.Page t of 3,'Emergen0y Response Phone 4,Manifest Tracking Number i
<br /> "4VA5 M MANIFEST ' -ALC SMS �� - 0 7 0, � V��
<br /> 5.Gepeiator's Name and Mailing Address $6' l Gendrafnes Site Address(if differenf thin mailing address)
<br /> 107 Lo °e A DTP, awa At a
<br /> TilrjaOZ CA"
<br /> GeneratofsPhone,
<br /> -
<br /> 6.'Transporter 1 Company Name U.S.EPAID Number
<br /> �1$��tt 7pn'A . f at t ura)§s 5 rade PHONE-'�'ost 1 39�3`8-004ma�a) CAR 7914.7
<br /> 7.Transporter 2 Company Name '. U.S.EPA ID'Number
<br /> 8.Designated F%111 Name and Site Address U.S.EPAID Number
<br /> a- �1
<br /> Facil!Vs Phone:
<br /> ga• 9b-U.S.DOT Description(including Propef Shipping Name,Hazard Glass,l0 Number, E 10:Conte}Hers 11:Total t 2.Unll 13.Waste Codes
<br /> HM and Pack ng Group(if any)) No• Type Quantity WI.N&
<br /> � �`�,F otst ,Budd,t�oz.(6€ ,.f is t� , ,�} 9 011
<br /> o X -
<br /> �' lei,D
<br /> -
<br /> LU 2:
<br /> Gt7
<br /> 14,Special Handling Instrucilons'andAdditional Information
<br /> D tmolret D3 S Solas,Qgt � �•l
<br /> -' 4 o '
<br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION;I hereby declare that the coptents of this consignment are fully and accurately described above by the propershippbg name,and are classified,packaged,'
<br /> marked and fabolodfpiacarded,and are in all respects fn proper condition for transport according to applicable International and national governmental regulations._If export shipment and I am the Primary
<br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknoWledgment of Consent.
<br /> I cel€t1y'fJtat the waste 1€tirli{alzat[onsJaf mgnt ldmffiivd in 40 CFR�6P,27(a)(if I am a jarge gLtagtity,gelrjalur)or(b)(if€am4$malt quantity genetptor) ,lure..
<br /> Genera rr lOffetors Printedlfp ed Name' Signature '` r Month Day 'Year
<br /> -� 16.-International Uhh pmenls.
<br /> i-. ❑Import to U,S. ❑Expartfrom U.S. Pari of entrylexit:
<br /> Transpoderslgnature(for exports only): 'Data leaving
<br /> 17.TranspofterAckhowtedg'ment of Receipt of Materials
<br /> o
<br /> Transporter)PrintedfTyped,Name Signature Month Day Year
<br /> V Tfanspoder2PrintedlTypedNama,:: Stgnafure -Mo
<br /> nth. pay Year
<br /> • fir .�t� `�,_r�-' ih:. _ iw.. - dr«'�,��:,,,,� (t .�':
<br /> fl.'D s ' c J dicot
<br /> 1 a. I prepa[r n f a pa o
<br /> e ecl'o `u!I Re eq
<br /> y �T g. O.R sidite' PaltjahR l rt, F J _,:
<br /> -
<br /> 3,
<br /> e''nr;e.Nu '6'eF
<br /> �s�; Marii•est=Refer. m -
<br /> _ f
<br /> - :� '• �'U.S:EPAID'Nu-'li r"..:
<br /> T eJ
<br /> -•€t8'S;�Af rdetr?'Faciii
<br /> uaac1lity�s Phone:
<br /> 180,Signature of'Altemate FaollfltifdrGerterator) Month Day Year
<br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous yrsste treatment,disposal,and recycling systems).
<br /> ua 1.
<br /> \ f
<br /> 20.Designated Facility Owneror Operator:Cerfif!catlon of;rgcelpt ofh`azanlous materials covered by the manifest-except as noted in Item 18a .
<br /> n _ - _ ."X;:�',':ra�..'.i ..:w"" --<.*�.c� `a�.;,;,: - - •.a=.i.-f Month- - •r) .aYear' - - -
<br /> ri ed. ed°{dam. fir.:=- r E.. �: :. .
<br /> l .,tYR : :i4x im:. . 'r'E•$jF{l lt[Fr2_., k ;.'F = :: R�=' _..
<br /> FPR'Form 87Q0-22((3ev,8-05) Previous editions are obsolete" :. DESIG AT15O FACILITY TO-GENERATOR.
<br />
|