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Form Anr%—,.d MAR K1. 9nrJUM0 <br />EPA Form 81VU-a (KOV. 4-M) Frevicrus editions are 0050=0- DESIGNATED FACILITY TO GENERATOR STATE (IF HF-CIIIJ11111hu) <br />11922.1528 1 - <br />ji. ua�,rl, Number <br />AJNIFORM HAZARROUS <br />Paige 1 of <br />Emergency Respcmse Phon�e 14. Me tT <br />WASTE MANIFEST CALDDDSOUI 1 <br />1 <br />0 <br />71- JJK <br />3.p"toes Name Address A Generators Site Address (t different than Meng address) <br />�m�Aqrupis iNc. <br />PRomiggLogr <br />i000 E. ,T�a <br />SMCKrOK CA 9M USA <br />Generat6es Phone, <br />6. Transporter I Company Name U.S. EPA ID Number <br />RAMOS EMARONWNTAL SERVICES INC. CADD44ODM <br />7.T" any Name U.S.Numb/erg <br />18. <br />Designated Facility Name and Site Address Z- U.S. EPA 10 Number <br />PACIFIC RESOURCE RECOVERY <br />31.60 EAST P= BLVD. CAD <br />LOS LES, CA SM <br />Facird rs Phone: na: 8013-4W145 <br />ga. <br />9b. U.S. DOT Description (mdudIng Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />41'. Total •12. <br />Unit <br />13. Waste Codes <br />No. <br />Type . <br />HM <br />and Paddrig Group (d any)) <br />.,, QXu <br />WIM- <br />TE <br />G <br />130 <br />MM <br />UA <br />.Z <br />2. <br />UJI <br />3., <br />4. <br />14. SirHaV %W28 Wf <br />Sm. =SRONMENTAL <br />E.R. <br />�.KAAIMERS SMAD BE TRAIM AND USE APPROVED PPE <br />Ix <br />16, GENERATWSIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are` Ry and accurately described al -e by the proper shaming name, and are classified, padcaged, <br />marked and lebeledliplacarded, and are In all respects in proper condition for transport acmrft to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Expor*, I certify that the contents of this consignment conform to the terms of the attached EPAAdmowledwrtent of Consent. <br />if I am a lenge quentity sqat"nfity generator) is hue. <br />1. certify that the waste minimization statement Identified in 40 CFR 262.27(a)g!2!Zor(b)(ffIama <br />Generatoes/OSigna)tM. Month Day year <br />ffemes M V I <br />.j <br />16, International Shipments❑ Import to U.S. ❑ Expert from U.S. Port of entrykidt: <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Adenowledgment of Receipt of Materials <br />signature Month Day Year <br />ix <br />Transporter 1 Printedfryped Name <br />9 <br />. . . 42 <br />Z <br />4 <br />Day <br />TIBMWOFIef-;� S. turs I - <br />� �4 <br />'00jj 1117 <br />18. Discrepai <br />T&� Partial Rejoin 18a. Discrepancy Indication Space ❑ ousedity E Residue 0 Full Rejection <br />Manifest Reference Number. <br />18b. Afternate Facility (or Generator) U.S. EPA ID Number <br />Facility. Phone: <br />U0 <br />18t Signature of Alternate Facro (or ggwrahr)­ <br />Month Day Year <br />.1c <br />19. Hazardous Waste Report Management Method Codes (.e., codes for hazardous waste treatment disposal, and recycling systems) <br />UJI <br />1. <br />2. 3. <br />4. <br />Designated Facility Owner or Operator Ceffication of receipt of hazardous ma*ji& covered by the manifest except as notedSlikipq <br />.Irri20 <br />Name Sig M P <br />c 6u6m <br />rx OA�J <br />EPA Form 81VU-a (KOV. 4-M) Frevicrus editions are 0050=0- DESIGNATED FACILITY TO GENERATOR STATE (IF HF-CIIIJ11111hu) <br />11922.1528 1 - <br />