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Please print or type. f=arm Approved.OMB lqo,20504W9 <br /> UNIFORM HAZAROOU5 I Generator ID Number 2.Page i cf 3.Emergency Response phone d.Manifest Tracldn urn er <br /> WASTEMANlFEST C °tCd �'-1 11 dd- 6.zq- cns 019 04268 JJK <br /> 5.Gorttrtatvs Nan M3jling Address Generators Siwe Address(if different Un mailing address) <br /> 50 11`4 L�mA �n `- <br /> Genar�tors�_ ��� <br /> 1A 415351 �� �� - Irel f CA '+53,16 <br /> U.Transporter 1 Company Mame U.S.EPA ID Nurnber <br /> Fd�d a E10 VA Y c ver CAOUS, 011 L4 <br /> T,Trnosporler y Company Name U.S.EPAID Number <br /> $.Desl$pa! F lhfy N C aqd ire drgss U.5.EPA If)Number <br /> Ls Sp3Iy� {VJ �Wj�r1 <br /> ra�lrtysPhe ° 1 '-l •SI (An OR$ Cq 019 . <br /> Ba. 9h.U.S.DOT Dusalption(lvcfuding Proper Shlppl%Mune,Hazwo Mass,id 1luntur, 14_Canlalno(S 11.Total 12.Unit 13.Waste Codas <br /> lilA rind Pocking Grorrp(it any)) <br /> No. Type t]uantily 4W NO. <br /> NA 19013r � Asrtt �k -�,3) � 0M 110Lu <br /> � <br /> w 2' <br /> to <br /> 3. <br /> d, <br /> 14.5VWol Handting Iashlxtlans alld AddiMQI!Earl a n <br /> # 'ISMO$ <br /> 15. GEN ERATOR'Slt}FFEROR'S CERTIFICATION t I hereby dcclaro Aiol the owntws of giLi conilgnrnonl are fully and mxuralely d=ribed above by tho proper shipping nama,rutl ate dessified,packaged, <br /> marked and laWailIplauanlad•and aro In all roSpoeWS In proper condition Tv transport aCC4&iq 10 pppllcalllo internnikallaland n001110 gavernnwnM(VAS90as,II arport shipment and I am iha Prlmnry <br /> Fxparter•I certify that the=Wnis of Ih19 wnsignmcnl canfarm to Iha terms of the attached kPAAckaotvfa gn*al of Consent. <br /> I orllfy urot the waste minlmlzmion slefemorlt Idendllnd In AO CFR 2621?(a)(If 1 am a largo quandly generator)or(b)(10 em a Small quem generator)Is tree. <br /> GendratrnWffumes PrinleWTypa Name Ig Wndr Day Year <br /> ow 10 19 <br /> � 1 .1 nrnallmul Shlpmcnti rf�� <br /> ❑impart Io-U.S. JJ Ettpart Um U.S. Purl of entryle„it, <br /> Transparlor slgnature(lir eKporlg Wy}: Oats leaving U.S.: <br /> W 17.TmnVWQrAzkA wfadgmrinlaiftooNpla(Matedala <br /> T6pedw1 Prinierlirypad Nam 5 v Mann pay Year <br /> IQ <br /> Tra2 PrintedlTyprd Name Sednature Mmul Day Year <br /> 1E.Uislxapancy <br /> i8a.Mscrapaney In4kullon Space ❑ Quantity ❑Sypn ❑Residue ❑Panlal Rejwjon ❑ru1i Relgctme <br /> Manlfesl Rolmunce Number <br /> 19-Allemate Fadfrly{or Gerivalw) U.S.EPA ID Number <br /> � Faci!itys Plrane: <br /> 1&.Signature of Plemiale Facility Of&noraw) Fdonth Day Year <br /> d <br /> z <br /> 19.Hazardous Waste Report Wanagemeni IAemDd Codes{I.e.,codes tar hazardous waste tresanent,disposxE,anb F"ng sy*-ms] <br /> C <br /> 1- 2. 3, 4. <br /> F20--D esignated Fachily(honer cv Operator Cedilcabim ol recalptoi hazardous maton&cowered by the mnn4est except at,rued in Item 189 <br /> PnnleWlypedltarna Signatwe Month Day Year <br /> EPA Form 874x22(Ruv.12.17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />