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Please print or .(Form designed for use on elite(12-plich)typewriter.) Form Approved.OMB No <br /> UNIFORM HAZARDOUS 1.GerveratorlD Number 2 Page 1 0[ 3. cY Response Phone 4.Manifest Tracking tVumber c <br /> WASTE MANIFEST e.r^i+ikf'W55`' ;: :i «'J�'? .,wc; 013 0 JJ <br /> 5.G a ngAddress <br /> Genrerato's SbAddress(if than mailing address). 1 <br /> an[ yrs aaf'T!',t{ui 's'+�M:. <br /> S.1: "t�T„ Y. ;5. St .r.lts.CA <br /> .�.r tr '9tli�t,% �il.D�J <br /> Generators Phone: <br /> 6.T xe0fge�'CqNaive ,.. u.S.ePA��t <br /> r t7g15? . <br /> 7.ThmsporW 2 any Namte ,.. U.&EPA ID Number <br /> &. . _ NOV 20-2015 <br /> 8.Des Ift a. U.S.EP <br /> 1�}E.+'�RLit�[lAsaf .)rfi AIp4.wa`"'e <br /> EIAKEWLELD,CA 93.307 ENVIRONMENTAL <br /> ^ ►;.,. HEALTH QhPARTMENT <br /> Ftys fes..:. - - <br /> ga. 9bU.S.DOT Descriptor prt rg Proper bfrippmg Name,Hazard Class 14 Number 10.Conlainets 11.Total 12.Unit '13.Waste Coda <br /> HM <br /> and Paddr9Qup(dany)) <br /> - No. _ Type Quantity WtNol, <br /> X 1. e . <br /> � aaK; <br /> 01 U <br /> r7 2 <br /> 3. <br /> 4. <br /> 44: <br /> 1t <br /> EFtt3Harxt Instmctio s and Addifional Information ' <br /> ff'3�dCiiet'?. rF;3Fif 'F <br /> 15. 'GENERATOR'SfOfFEROR'S CERTiRCATtON:!hereby declare That the contends of its cunskgnment are ft*and accurately described strove by the proper shipping name,and are dasstted,pad"ed, <br /> marked and d and are in at respects in proper condition forlrensporlacdmg to apptcehle intemationaland nationd gavarmmcrttaf regulatiers.H effort shlprmenland I am ttq Prime <br /> ry <br /> Exporter,I carffy 9W the contents of this consignment codons to the terns of the attached EPAAdcnowledgment of Consent. <br /> I=*that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifl am a small quantity generatorjis true. <br /> Gernerator'slOfreroPs PdnWTyped Name Signahrre Month Day Year <br /> JX. t tl <br /> .J 16.International Shipments <br /> ❑ mU.S. <br /> import to U.S. ❑Export U S Port of ardrytaxi(: <br /> ? Transporters-ture(for exports only): Date leaving U.S.: <br /> 17.Tr4r sWerAdmmAedgment of Receipt crWedals <br /> Transpjjii&1 PlIodlTyped Name Signatuia Month' Day Year <br /> a 114-1ca L • .� f <br /> ZTraMporter 2 Pdn Name Signature Month Day Year <br /> 18a:Discrepancy indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection Nil Rejection <br /> Manifest Refereme Number: <br /> 18b.Altemate Faciltiy(or Generator) U.S.EPA ID Number <br /> V <br /> LL. Facilty's Phone: <br /> a 18c Signature ofAllemateFadTdy(orGeneraterj Month,. Day Year <br /> 2 <br /> as 19.Hazard6us Waste Rapqrt Management Method Codes(Le.,codes for hazardous waste treatment,dlsposA and recyrclin j systems) <br /> ® �' f <br /> 12. 3. 4. <br /> LI20.Designated Facility QwW or Onerstm Certification of receipt of hazardous materials covered by the manifest except as ncted in tem 18a <br /> Prkntedfryped Name4 r i SignatureMonth Day Year <br /> EPA Form 87411-22(Rev.3-05)''Pre4itts editions are obsolete. a,,, <br /> R 14SPORTF:rt S COPY <br />