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Please print or type.(Form designed for use on elite(12-pit ter.) Form Approved.048 No. {� UNIFORM.HAZARDOUS 1.Generator ID Number 11111110F 2.Pagel of 3.Emergency Response Prwne' 4.Manifest Tracks umber 'J WASTE MANIFEST C,41JX0> ' S Yd 8:.t- 'id s 012/,4, 3 0 0 8 ry.sJJ K 5.Generators Name and Mailing Address Generatoes She Address(V different than mating address) P.O.E1t;7Y, wTOCKTOPJ,CA 95: �Tt3U^x:Tigtd,ti . GenerabDes Phone: q 4.2531"12 S.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name UA EPA ID Number ) &Des F Name and Site Address A 1, O O U.S.EPA ID Number i p p.o ylv TRJhJUrG}xaAme 6nER(rtitG. 'YU Y tk4is i`24 ;a + F s"Pttortei �61=32# 8 ENVIRONMENTAL HM aW Paddng Group(i<any))nduding Proper Shipping Name,Hazard C! No m Type Q.varTtdty Wt VM 13. �.U.S.DOT VNesfe Codes 3l 1' fnlCgN ';L b folly 469tft171?'{fTt ► Ts e i Z. LLS ca 3. 4. 14.Spec41 Handling InsUtrctions and Additional Information ERG V 171R 1t�CtlC� a t�t)'t ILew c S CR 1313-U3-�6T r 15. GENERATOR'SI0FFER0R'S CERTIFICATION:I hereby declare that the contents of this conslgnment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledlphacarded,and are in all respects in proper condom far transport acxxuding to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I ce*that the contents of this consignment conform to the terms of the attached EPAAdaaxfedgment of Consent. I certify that the waste minimization statement Identified in 40 CFR 26227(a)(if I am a large quantity generato)or(b)(if I am a small quantity generator)is true. e r+m Genenater Rrirn Signrj M � Month Day Year . Nrg ' -J 16.Intematicnal Shlpmenls ❑import to U.S. ❑Export from U.S. , Part of enbyfexil: Transporter signature(forexports 001y): Date leaving U.S.: W 17-TimnsporterActknowledgment of Receipt of Materials 7ransprs Signature ! Month Day Year a161Transparter2Prknt ante Signature Month Day Year 1-- 1&Discrepancy 18a.Discrepancy Indication Space 11Quantity ElType ❑Res duo ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Fad14(or Generator) U.S.EPA ID Number 'V 4Q FacdlVs Phone: kj 18c.Signature ofAlternate Facility(or Generator) Month Day Year L~ 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste 9eabnant,disposal,and recycling systems) L. 2. 3. a s 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials cowed by the manifest except as noted in Item lea n Priv yp 1 t Signature1 12 _ - ra o fl, Day r AIA Form 87OD-22(Rev.3.05) Previous eddions ate obsolete. 7AANSPOR TER'S COPY _ _.