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- <br /> -r. Jv <br /> Please print or type. Form Approved.OM 3 No.2050 0039 <br /> 1.Generator IQ Number 2.Aa <br /> UNIFORM HAZARDOUS Beryl-of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C.Rf�J 3.9[196#T3 �` 915-371�37d? ?`j �1 JA <br /> K , <br /> 5.Generators Name andlrledittg-Address Generator's Site Address(if different than mailing address) <br /> ATtf=Fl C AVIA11ON <br /> 6364 S. LINDBERGH ST <br /> STOW01%CA, 952116 <br /> Generators Phone2-09-534 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number � <br /> #"SAMOS FM1tLRRONt�lEi�"fAL SERVICI"S INC. GRW44r <br /> spP1,�6 <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address PACIFIC RESOURCE RECI r U.S,EPA ID Number <br /> 3150 EAST Pico iI 0r`tD0052-52445 <br /> LOS ANGELES,CA M023 <br /> Facility's Phone:€0D-4qg-7145 <br /> 9a, 9b.U S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WtJU01. 13.Waste Codes <br /> o �� UKJ <br /> 1. �t15d1uA,� -f, 5;C]Li JE,3,FeGil <br /> F- <br /> � <br /> t.rt <br /> Z 12. <br /> w <br /> C'7 <br /> 3, <br /> 4. <br /> 4.Special Handling Instructions and Additional Information € <br /> 961)P€OF11I ERGM28 lA.A <br /> HANDLERS TO BE TRAINED AND USED APPROVED PPE. <br /> E.R. GONTRACToR: RAi os ENVIRONMENTAL SEiRMCES <br /> 15. GEN ERATOR'SIOFFEROR'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, <br /> marked and labeledlplacarded,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 <br /> Exporter,I certify that the contents of this consignment conform t0 the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27{a)(if I am a large quantity generator)or(b)(ifI am a small quantity generator)is true. <br /> Goner f0r`slOifero s PrrntedfTyped Na Signature Month Da Year <br /> _j 16 International Shipments <br /> Z ❑import t0 U.S. Ll Export from U.S. Port of entrylexft: <br /> Transporter signalure(for experts only): Date leaving U.S.: <br /> Le W <br /> 17.Transporter Acknowtedgment of Recelpt of Materials <br /> r- Transporter PlintedlTyped Na a Month Day Year <br /> r Signature <br /> O <br /> CL <br /> z J ransporler 2 PinledlTyped Name y, Signature <br /> f Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indlcali0n Space Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> H 10b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: i <br /> coir 1 Be.Signature of Alternate Facility(or Generator) hAonth Day car <br /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. � } 3.12. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ha <br /> Pdnledlfyped Name Signaaturl M_ _ M ith y Year <br /> EPA Form 8700.22(Rev.12-17) Pr�RoO editions are obsole e. -DMF3NATE0TAMITYTU GENERATOR <br /> s <br /> I <br />